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training courses 

Supporting pharmacy success 


patient care 

Pfizer commitment 
to pharmacy 

As part of a healthy partnership"" out commitment is to 
listen to you, the community healthcare experts. We want 
to understand the professional issues facing community 
pharmacy so that when we act to develop support and 
training, it meets your professional development needs, 
helping you and your pharmacy succeed. 

Our MUR workshops have proved successful and we are 
continuing to develop further "soft skills" training to help 
you counsel patients, implement pharmacy services and to 
help grow your pharmacy. 

For the most up-to-date details on our "soft skills" 
meetings please visit 
(insert code R948 on first page). 

Listening to pharmacy 

a healthy 

HP 0358. Date ol preparation: May 2010. 

Have your say on C+D's news. Email us at: 


Croup Editor 

Gary Paragpuri MRPharmS 
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firstname. surname 

Cover: Getty Images 

£the health 
secretary said he 
was keen for 
pharmacists to 
play a greater 


There's a GP in the office who sits 
about five desks away and, despite 
the promise of £80 billion coming 
his way, he's not a happy bunny 

I suspect the enormity of the task 
foisted upon his shoulders by the 
health secretary Andrew Lansley in 
this week's health white paper has 
just hit home. Along with his 36,000 
GP colleagues, he will be charged 
with taking responsibility for 
delivering cost-effective, clinically 
sound NHS services across England. 

Aside from shifting commissioning 
responsibility to the proposed GP 
consortia, Mr Lansley has ruthlessly 
swept away PCTs and strategic 
health authorities, as he looks to cut 
billions from the NHS budget - a 
move that will be cheered by 
pharmacists. While PCTs were a 
good idea, their general inability to 
engage wholeheartedly with the 
country's biggest network of health 
providers has been shameful. 

Furthermore, a new NHS 
commissioning board will take over 
responsibility for England's 
pharmacy services. This will, through 
"payment for performance", 
incentivise high quality and efficient 
services. And pharmacists have an 
"important and expanding role" and 
will benefit from "greater 
transparency in NHS pricing and 
payment for services", we are 
promised. It all sounds great - a rosy 
future for the sector. But it wouldn't 
be the first time ministers have 
promised to tackle the sector's woes. 

And this week's NHS blueprint is 
again high on vision and low on 
detail, leaving pharmacists with a 
plethora of unanswered questions. 

With PCTs being scrapped, what 
happens to the global sum and 
pharmaceutical needs assessments? 
If the NHS commissioning board is 
not going live until 2012, what does 
this mean for the pharmacy contract 
- are negotiations on hold for two 
years and will the cost of service 
inquiry data be out of date? And just 
what role will pharmacy play in 
supporting the new GP consortia to 
deliver their objectives? 

A chance comment in C+D's sister 
title Practical Commissioning does, 
however, offer a useful insight Its 
regular diarist, Peter Weaving, a GP 
and locality lead in Cumbria, 
describes a meeting he had with Mr 
Lansley just a few days prior to the 
health white paper's publication. 
Asked about pharmacy, the health 
secretary told him he was keen for 
pharmacists to play a far greater role 
in managing people's health and 
described the sector as hugely 
competent and hugely underused. 
Interestingly, Dr Weaving says Mr 
Lansley believed pharmacy's 
national contract was ridiculous and 
should be determined locally. 

Quite how locally determined 
contracts will fit with a sector that is 
dominated by national chains is 
unclear. It looks as if PSNC will face 
some difficult discussions both with 
its members and the new NHS 
Commissioning Board. But if the 
potential rewards mean community 
pharmacy finally has the platform to 
demonstrate just what it is capable 
of, the pain of another contract 
upheaval could be bearable 

Gary Paragpuri, Editor 

4 PCTs scrapped under white paper 

5 Pharmacy pay to reward quality 

6 Cat M compensation for Nl pharmacy 
8 PCTs issue clopidogrel dictat 

10 GSK campaign backs toothpaste launch 

12 Vive la white paper revolution? 

13 Xrayser and Ronan Brett 
30 Postscript 

Update - End of life care: part 1 

Pain control in palliative care 

18 Practical Approach 

Antibiotic prescribing in epilepsy 

19 Category Focus: Incontinence 

It may be an embarrassing subject, but it's lucrative 

22 The coalition script 

How government policies will affect pharmacy 

25 Jobs 

Seven steps to making a good impression 

© UBM Medica, Chemist+Druggist incorporating Retail Chemist, Pharmacy Update and Beauty Counter Published Saturdays by UBM Medica, Ludgate House, 245 Blackfnars Road, London SET 9UY. C + D online at 
www.chemistanddruggist Subscriptions: With C + D Monthly pricelist £250 (UK), without pricehst £205 (UK). ROW price £365. Circulation and subscription UBM Information Ltd, Tower House, Sovereign Park, Lathkill St, 
Market Harborough, Leics. LE16 9EF. Telephone: 01858 438809 Fax: 01858 434958. Refunds on cancelled subscriptions will only be provided at the publisher's discretion, unless specifically guaranteed within the terms of 
subscription offer. The editorial photos used are courtesy of the suppliers whose products they feature. We are not responsible for the content of any external websites referred to in this magazine All rights reserved No part of 
this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including photocopying, recording or any information storage or retrieval system without the express prior written consent 
of the publisher The contents of Chemist + Druggist are subject to reproduction in information storage and retrieval systems UBM Information Ltd may pass suitable reader addresses to other relevant suppliers If you do not wish 
to receive sales information from other companies please write to Emily Miles at UBM Medica Origination by ITM Publishing Services, Central House, 142 Central St, London EC1 V 8AR. Printed by Headley Brothers Ltd, The Invicta 
Press, Queens Road, Ashford TN24 8HH. Registered at the Post Office as a Newspaper. Volume 274 No 6756 

17.07.10 3 


PCTs scrapped under Lansley's 
radical health white paper 

Pharmacy to be commissioned by new board 

Hannah Flynn 

h anna h.f ly nn@u b m.c o m 

PCTs will be scrapped under plans 
outlined in the health white paper, 
presented to Parliament by the 
health secretary, this week. 

Andrew Lansley outlined plans on 
Monday to transfer commissioning 
roles to CPs, a new NHS 
commissioning board and local 
authorities from next year. 

Pharmacy services will be the 
responsibility of the NHS 
Commissioning Board. But CP 
consortia will have influence and 
involvement in decisions, the paper 

The 61-page health white paper 
makes four explicit references to 
pharmacy. These include a 
commitment to incentivise the 
sector through payment for 
performance under a new contract. 

The sector will also benefit from 
plans to make NHS payments and 
services more transparent, the 
government stressed. 

However, immediate reaction to 
the white paper was dominated by 
concerns over GP consortia. 

Ash Soni, contractor at Copes 
Pharmacy, London, and PEC 
chairman, demanded safeguards 
to stop CPs monopolising funds 
on BBC's Newsnight this week. 

"If you make [commissioning] 

transparent and involving patient 
choice, pharmacy is in a strong 
position. But you need these 
safeguards built in," he told C+D. 

Mr Lansley, who also appeared on 
the programme, stressed that CP 
consortia would involve other NHS 

He said: "It will be general 
practice-led commissioning, not 
general practitioner-led 
commissioning... the delivery of 
primary care depends on a 
multidisciplinary team." 

Over 500 CP consortia could take 
on funds from 2013 under plans. The 
model will be in place in shadow 
form from 2011. 

Public health service funding will 
rest with local authorities under 
proposals. Authorities will be guided 
by "health and wellbeing boards" 
charged with joining up the 
commissioning of NHS service, 
social care and health improvement. 

The move was a positive one for 
pharmacy, said Sue Sharpe, PSNC 
chief executive. "Pharmacies are well 
placed to build links with local 
councils and are ideally placed to 
help them." 

Mrs Sharpe also backed the white 
paper's reforms around primary care 
commissioning. She added: "The 
development of community 
pharmacy services has for too long 
been held back by the vagaries of 

Lansley's key reforms 

• PCTs abolished by 201 3 

• New NHS commissioning board to 
be responsible for pharmacy services 

• GP consortia to direct local NHS 
commissioning groups will be open 
to pharmacists 

• New pharmacy contract to be built 
on payment by performance 

• Greater transparency in NHS pricing 
and payment for services 

patchy PCT commissioning, and this 
process of reform represents an 
opportunity to find a better, more 
cohesive way of ensuring all 
communities can benefit from high 
quality pharmacy services." 

White paper 

Patients to decide providers 

Patients will have a greater say over 
who provides their healthcare and 
what treatment they are given 
within four years, the government 
has announced. 

The plans, part of a drive to 
increase patient choice under the 
mantra "no decision about me 
without me", were set out in the 
health white paper. 

Under the white paper plans, 
patients will be offered the choice of 

"any willing provider" to deliver 
health services. Other key aspects 
include patient control over who has 
access to health records and a 
rollout of personal health budgets. 
Choices over diagnostic testing will 
ho intiodiK ('(I from next yen, with 
choice over some mental health 
services from April. 

"We expect choice of treatment 
and provider to become the reality 
of patients in the vast majority of 
NHS-funded service by 2013-14," 
the white paper states. 

Writing to health secretary 
Andrew Lansley, NPA chair Ian Facer 
welcomed the move to place patient 
choice at the heart of health agenda. 

He said: "The voice of patients 

should be paramount. This is right 
in principle and practice, and can 
only be good news for pharmacists 
because of the bond of trust that 
already exists between us and our 

To ensure all patients have a voice, 
the government will create an 
independent consumer champion, 
Health Watch England, to ensure 
patients are able to feed back about 
local services and commissioning. 

However, the proposals were 
welcomed cautiously by The 
Patients Association director 
Katherine Murphy, who warned the 
redesign of the NHS structure could 
cause instability, and there was "a 
long way to go". CC 

Commissioning reforms: 

Publish white paper on public 
health plans 2010 
Launch NHS Commissioning 
Board in shadow form April 

■ Launch GP consortia in 
shadow form April 201 1 

• Scrap PCTs 2013 

: GP consortia to take on full 
commissioning powers April 



i Announce principles behind 
new financial allocation 
process April 2011 

Extend payment by results to 
community services April 


Ring-fenced public health 
budgets allocated in shadow 
form April 2012 

PSNC chief takes the 
positives from the paper 

4 Chemist Druggist 17.07.10 

Check out our interactive guide to what's hot and what's not in the white paper 

Pharmacy pay to 
reward quality 

Performance linked to pay in new contract 


Every day, millions of people visit 
their community pharmacy for 
advice and treatment. 

Community pharmacies are 
deally placed to conveniently 
deliver a wide range of health 
services close to people's homes. 

We have just published our white 
Daper- Equity and Excellence: 
iberatingthe NHS. It presents 
Dharmacies with a tremendous 
opportunity for working more 
:losely with the public, patients, 
doctors and other health 
Drofessionals, to support better 
lealth outcomes. 

I want community pharmacists to 
expand the range of clinical and 
public health services they deliver I 
want them to help patients get the 
nost from their medicines, to better 
manage their conditions, to focus on 
prevention as well as treatment, and 
o help patients be better informed 
and more involved with their care, 
lommunity pharmacies can help to 
educe health inequalities and 

Zoe Smeaton 

Community pharmacists must 
prepare for a new contract that will 
reward quality of service delivery 
rather than dispensing volume, 
industry leaders have warned. 

The comments came as the 
government's white paper said the 
sector would be paid for performance 
in the future and would benefit from 
"greater transparency in NHS pricing 
and payment for services" 

The changes would come alongside 
a shift towards value-based pricing 
for medicines, the paper said. 

"The community pharmacy 
contract, through payment for 
performance, will incentivise and 
support high quality and efficient 
services, including better value in the 
use of medicines through better 
informed and more involved 
patients," the document stressed. 

Faisal Tuddy, commercial manager 
on the pharmacy team at Asda, 
said: "To achieve the government's 
stated outcomes we will need a 
new pharmacy contract that puts 

the needs of patients first. Anything 
less will just be tinkering around 
the edges." 

Asda added that the changes 
would be challenging for some 
pharmacists as remuneration moved 
from dispensing to other services. 
Mark James, managing director at 
AAH, warned that any future funding 
based on performance needed to 
fairly reward the sector. And Avicenna 
CEO Salim Jetha said payment on 
outcomes "must not be riddled with 
excessive administration burden". 

Jonathan Mason, the Department 
of Health's community pharmacy 
tsar, said: "Pharmacy remuneration 
may well need to change if [the 
government] is going to incentivise 
pharmacists as medicines 

But the sector could benefit from 
greater transparency in payments, 
the NPA said, as community 
pharmacy-based services were 
"among the most cost-efficient". It is 
hoped the transparency may help to 
end the variable pricing for 
pharmacy services, as shown by 
C+D's PCT Investigation last year. 

Pharmacy minister's verdict on the white paper 

prevent people from getting ill by 
helping them to change the way 
they live their lives. 

Pharmacy services will benefit 
from greater transparency in NHS 
pricing and payment for services. 
Through payment for performance, 
those who deliver high quality 
patient care and NHS services 
that are safe and clinically 

effective will be rewarded. 

The NHS Commissioning Board 
will be responsible for 
commissioning a range of family 
health services, including 
community pharmacy. We will look 
at what further changes we need to 
make to provide better, more 
patient-centred healthcare. 

Many community pharmacies 
already do excellent work to 
improve the public's health. As the 
public health service emerges, I 
want to see far more pharmacies 
following their example, working 
with their local authority and 
director of public health 

I am looking forward to working 
with you all to ensure that 
community pharmacy plays a 
vital role in delivering the 
government's priorities for the 
National Health Service 
Earl Howe, pharmacy minister 

"We now need to 
see much greater 
clarity and detail. 
I hope ministers 
and officials 
recognise funding 
not only needs to 
be performance- 
related and transparent, it also needs 
to fairly reward the professional 
contribution of pharmacists and be 
sufficient to sustain the community 
pharmacy network." 
Mark James, AAH MD 

"I think overall 
this is positive for 
although I know 
some pharmacists 
might not think 
that. There is a 
very positive line 
[about pharmacists having an 
important role in optimising the use 
of medicines and supporting better 
health] and we can badge a lot of 
what we do on the back of that " 
Jonathan Mason, DH community 
pharmacy tsar 

"Pharmacy does 
get a mention, 
but how exactly it 
will fit into the 
structure is not 
very clear at all. 
We may feel we 
have been getting 
somewhere with our PCTs regarding 
commissioning of services, but if 
they are then scrapped it is back to 
square one." 

Cordon Couper, Handbridge 
Pharmacy, Chester 

More views at www.chemistand 

"It takes me 
back to the days 
when local 
surgeries could 
hold funding and 
control quite a bit 
of money. If it is 
like that then I 
have been there and I survived it." 
JohnThroup, Burrows & Close 
Pharmacy, Calverton 

Get more health white 
paper verdicts onlin 


17.07.10 Chemist Dru 5 


Get the latest health news emailed to you daily 

Boots video interviews 

Alliance Healthcare executives 
highlighted their continued 
commitment to services and 
partnerships at the opening of its 
Exeter service centre on Monday 
July 12. Watch C+D's video 
interviews with Alliance Boots 
executive chairman Stefano 
Pessina, group chief executive 
Andy Hornby and pharmaceutical 
wholesale division head Ornella 
Barra from the event last week. 

Cloiiuicat stody days 

Pharmacists are invited to attend 
two UK Clinical Pharmacy 
Association study days on allergy 
and asthma, and cardiology. The 
allergy and asthma event takes 
place at the Leicester Ramada on 
October 7, while the cardiology 
day is on September 17 at The 
Studio, Birmingham. 

Teva recall 

Teva UK has recalled all remaining 
stock of three batches of 
glibenclamide tablets that may 
not meet the specifications for 
tablet dissolution 12 months from 
manufacture. The batches are 
glibenclamide 5mg tablets in Teva 
UK livery batch 000537, expiry 
September 2012, 1x28, and batch 
001315, expiry September 2012, 
1x28; and in Generics (UK) livery 
batch 000681, expiry September 
2012, 1x28. 

Weight loss clubs best 

Two studies of a selection of 
popular slimming supplements 
have found no evidence they help 
patients lose weight beyond the 
placebo effect, the International 
Congress on Obesity has heard. 
But a third study revealed 
structured programmes to aid 
weight loss can be effective. 

Phoenix funding 

The parent company of Phoenix 
Medical Supplies has secured 
finance for its long-term future in 
Europe, the group has announced. 
Phoenix UK CEO Paul Smith said 
he expected the new financial 
structure to enable the wholesaler 
to consolidate its existing position 
and continue growth in the UK 
pharmaceutical market. 

Nl pharmacy gets £28m 
Cat M compensation 

Settlement will relieve "immense financial hardship", says PCC 

Hannah Flynn 

Pharmacists in Northern Ireland 
(Nl) will receive £28 million in 
compensation for outstanding 
money owed to them from illegal 
category M reductions. 

The money will be sent to 
individual contractors following an 
agreement between the 
Pharmaceutical Contractors 
Committee Nl (PCC) and the 
Department of Health, Social 
Services and Public Safety (DHSSPS). 

The settlement follows a 
judicial review ruling in PCC's favour 
earlier this year, which decided Nl 
pharmacies were entitled to receive 
payment for outstanding category M 
monies for the period 2007-10. 

Loretta McManus, of Erne 
Pharmacy, Enniskillen said she was 
pleased the settlement has been 
reached as the talks were long and 
drawn out. 

Ms McManus said: "For many 
contractors category M was a 
breadline matter. I know contractors 
who couldn't take on a second 
pharmacist because of category M, 
and even had to worry about the 
impact this would have on their 
ability to take out loans. It has been 
a very serious matter." 

In a letter to contractors in Nl, 
PCC chief executive Gerard Green 
said: "PCC is acutely aware of the 
immense financial hardship endured 
by contractors as a result of 
category M over recent years which, 
in turn, is being compounded by the 

current difficult economic and 
financial climate." 

Mr Green went on to say interim 
arrangements have been made for 
the financial year 2010-11, when 
additional funding will be made 
available to contractors in respect to 
category M. The letter also outlined 
plans for new contract discussions. 

He added: "Furthermore PCC and 
DHSSPS have agreed to 
recommence new contract 
discussions and negotiations 
immediately, so that new 
arrangements, including a new 
Nl Drug Tariff, are in place post- 
March 2011." 

Mr Green said he hopes the 
settlement goes some way to 
reinstating an element of financial 
stability for contractors. 

Clinical debate C+D's Chris Chapman looks at the evidence behind the headlines 

Better clinical outcomes ahead? 

In the whirlwind of change 
sweeping through the NHS in the 
wake of Andrew Lansley's white 
paper, it's easy to forget its focus is 
on improving patient care. The 
essential question has to be 
whether the paper bodes well for 
the nation's health - and that 
comes down to the nitty gritty. 

The problem is that every 
clinical win is held back by a 
caveat, mostly due to the white 
paper's (necessarily) top-line view. 
Take pharmacy services, which will 
be commissioned from a 
centralised body. This could end 
the current patchy commissioning, 
and allow pharmacists to work in 

different areas without having to 
prove their clinical skills repeatedly. 

But with the current lack of detail 
on just how this commissioning 
board will work, it's hard to tell how 
services will develop. 

The suggestion of a performance- 
based framework also raises key 
clinical questions. While rewarding 
those who deliver quality outcomes 
ties in with the 2008 pharmacy 
white paper, some argue GP-style 
QOFs haven't always been drafted in 
a way that drives patient outcomes. 
Last year National Obesity Forum 
chair David Haslam criticised the 
system, stating with the QOF he was 
"incentivised to identify fat people 
and make a list of them, and with 
the list do absolutely nothing". You 
might say the proof of the pudding 
for pharmacy will be in the eating. 

Self-care is a potential winner, 
too. According to the Self Care 
campaign, up to £2 billion could be 
saved by encouraging patients to 
self-treat rather than present to a GP. 
A pharmacy-based minor ailments 
service would seem a logical step - 
but there's no mention of a national 
rollout in the government's plans. 

The only definite winner in the 
future is evidence-based 
medicine. After a quick probing 
from MP David Tredinnick on 
whether homeopathy would be 
more widely available, Mr Lansley 
said commissioning would be 
based solely on "scientific 
evidence, clinical evidence and 
guidelines". Isn't that about as 
close to 'no' as you can get 
without saying it? 

Only time will tell if the white 
paper truly serves up The Greatest 
Healthcare Revolution Since The 
Founding Of The NHS (™). For the 
moment, although the rumbles 
from Whitehall are positive, it's 
too early to say what the 
proposals will mean for frontline 
clinical care. 

To discuss this subject in 
private with your pharmacy 
colleagues, join the debate in 
C+D's Linkedin group at - search for 
Chemist and Druggist. 

Chat with Chris on Twitter: 

6 Che gist 17.07.10 


In January 2009 Allen & Hanburys launched Avamys' ▼ (fluticasone furoate), an intra-nasal 
steroid (INS) for treatment of the symptoms of allergic rhinitis. 1 Avamys (fluticasone furoate) is a different 
chemical entity to Flixonase® (fluticasone propionate) and is therefore a distinct drug molecule and not 
a salt or a prodrug of fluticasone propionate. 2 

A survey taken in May 2009, amongst 128 pharmacists showed that: 3 

• 31% were unaware of this INS (Avamys, fluticasone furoate). 

• 63% were not aware of the differences between fluticasone furoate and fluticasone propionate. 

Allen & Hanburys would like to highlight the important key differences that will support you in dispensing 
the right medicine. 


fluticasone propionate 4 ' 5 

Dose per spray 



Sprays per pack 



Licence Age 

6 years and older 

4 years and older 

Cost (on prescription) 



In a single dose study comparing Avamys to fluticasone propionate nasal spray, patients preferred 
Avamys over fluticasone propionate based on sensory attributes. 6 Avamys provides relief from both 
nasal and ocular symptoms in an advanced device. 7-10 Avamys is available to purchase from AAH and 
Alliance Healthcare. 

Prescribing Information 

(Please refer to the full Summary of Product Characteristics before 

Avamvs 6 ^ Nasal Spray Suspension 
(fluticasone furoate 27.5 micrograms/metered spray) 
Uses: Treatment of symptoms of allergic rhinitis in adults and 
children aged 6 years and over Dosage and Administration: 
For intranasal use only Adults: Two sprays per nostril once daily 
(total daily dose, 1 1 micrograms). Once symptoms controlled, use 
maintenance dose of one spray per nostril once daily (total daily 
dose, 55 micrograms). Reduce to lowest dose at which effective 
control of symptoms is maintained. Children aged 6 to 11 years 
One spray per nostril once daily (total daily dose, 55 micrograms). 
If patient is not adequately responding, increase daily dose to 
110 micrograms (two sprays per nostril, once daily) and reduce 
back down to 55 microgram daily dose once control is achieved 
Contraindication: Hypersensitivity lo active substance or 
excipients. Side Effects: Systemic effects of nasal corticosteroids 
may occur, particularly when prescribed at high doses for prolonged 
periods Very common: epistaxis. Epistaxis was generally mild lo 
moderate, with incidences in adults and adolescents higher in 
longer-term use (more than 6 weeks). Common: nasal ulceration. 
Rare hypersensitivity reactions including anaphylaxis, angioedema, 
rash, and urticaria. Precautions: Treatment with higher than 
recommended doses of nasal corticosteroids may result in clinically 
significani adrenal suppression. Consider additional systemic 
corticosteroid cover during periods of stress or elective surgery. 
Caution when prescnbing concurrently with other corticosteroids. 

Growth retardation has been reported in children receiving some 
nasal corticosteroids at licensed doses. Monitor height of children 
Consider referring to a paediatric specialisl May cause irritation of 
the nasal mucosa. Caution when treating patients with severe liver 
disease, systemic exposure likely to be increased. Nasal and 
inhaled corticosteroids may result in the development of glaucoma 
and/or cataracts. Close monitoring is warranted in patients with a 
change in vision or with a history of increased intraocular pressure, 
glaucoma and/or cataracts Pregnancy and Lactation: 
No adequate data available. Recommended nasal doses result in 
minimal systemic exposure. It is unknown if fluticasone furoate 
nasal spray is excreted in breast milk. Only use if the expected 
benefits to the mother outweigh the possible risks lo the foetus or 
child. Drug interactions: Caution is recommended when co- 
administering with inhibitors of the cytochrome P450 3A4 system, 
e.g. ketoconazole and ritonavir. Presentation and Basic NHS 
cost: Avamys Nasal Spray Suspension: 120 sprays: £6.44 
Marketing Authorisation Number: EU/1/07/434/003. Legal 
category: POM. PL holder: Glaxo Group Ltd, Greenford, 
Middlesex, UB6 ONN, United Kingdom. Last date of revision: 
January 2010 

Adverse events should be reported. Reporting forms and 
information can be found at Adverse 
events should also be reported to GlaxoSmithKline on 
0800 221 441. 

Avamys is a registered trademark of the GlaxoSmithKline group of 


1. Avamys Summary of Product Characteristics 2009. 

2. Salter M, Biggadike K, Matthews JL et al Am J Physiol Lung Cell Mol Physiol 2007: 293: 660-667. 

3. GlaxoSmithKline Data on File AVS/DOF/09/42575/1 . 

4. MIMS (Monthly Index of Medical Specialities). Online, last accessed date April 2010 

5. Flixonase Summary of Product Characteristics 201 0. 

Avoid concomitanl administration of inhibitors of the 
cytochrome P450 3A4 system, e.g. ketoconazole, and ritonavir. 
Pregnancy and lactation: Clinical data is not available. Balance 
risks against benefits. Side effects: Very common: Epistaxis 
Common: Headache, unpleasant taste, unpleasant smell, nasal 
dryness, nasal irritation, throat dryness, throat irritation. Very 
rare: Cutaneous hypersensitivity reactions, angioedema, 
bronchospasm, anaphylactic reactions, glaucoma, raised 
intraocular pressure, cataract, nasal septal perforation. 
Presentation and Basic NHS cost: Flixonase Aqueous Nasal 
Spray: 150 metered sprays - £11.01. Market Authorisation 
Number: PL 10949/0036 Market Authorisation Holder: Glaxo 
Wellcome UK Limited trading as Allen & Hanburys, Slockley Park 
West, Middlesex, UB11 1BT Legal category: POM Date of 
preparation: January 2010. 

Prescribing Information 

(Please refer to the full Summary of Product Characteristics 
before prescribing.) 

Flixonase" Aqueous Nasal Spray 
(fluticasone propionate 50 micrograms/metered spray) 
Uses: Prophylaxis and treatment of seasonal allergic and 
perennial rhinitis in adults and children aged 4 years and over. 
Dosage and administration: For intranasal use only. Adults: Two 
sprays per nostril once daily in the morning. Once symptoms 
controlled, use maintenance dose of one spray per nostril once 
daily. Two sprays per nostril twice daily may be required 
Maximum daily dose lour sprays per nostril. Children aged 4 to 11 
years. One spray per nostril once daily in the morning. One spray 
per nostril twice daily may be required Maximum daily dose two 
sprays per nostril. For full therapeutic benefit regular usage is 
essential. The minimum dose should be used al which effective 
control of symptoms is maintained Contra-indication: 
Hypersensitivity to any of ils ingredients. Precautions: Local 
infections should be appropriately treated. Caution when 
transferring patients from systemic steroids. Systemic effects of 
nasal corticosteroids may occur at high doses for prolonged 
periods. Growth retardation has been reported in children 
receiving some nasal corticosteroids a* licensed doses Monitor 
height of children. In addition, consider referring patients to a 
paediatric specialisl. Treatment with higher than recommended 
doses of nasal corticosteroids may result in clinically significant 
adrenal suppression Consider additional systemic corticosteroid 
cover during periods of stress or elective surgery 

6 Meltzer E, Stahlman J ef a/ Clin Iter 2008; 30: 271-9. 

7. Fokkens WJ, Jogi R, Reinartz S ef al Allergy 2007, 62: 1 078-1 084. 

8. Kaiser HB, Naclerio RM, Given J etal J Allergy Clin Immunol 2007, 119(6); 1430-1437. 

9. Jacobs R, Martin B, Hampel F ef al. Curr Med Res Opin 2009, 25: 1 393-1401 . 
10 Berger WE, Godfrey JW, Slater AL Exper Opin Drug Deliv 2007, 4(6): 689-701. 

Adverse events should be reported. Reporting forms and 
information can be found at Adverse 
events should also be reported to GlaxoSmithKline on 
0800 221 441. 

Flixonase is a registered trademark of the GlaxoSmithKline group 
of companies. 


For more information on Avamys visit 

Date of Preparation: May 2010 UK/FF/0070/10 



Daily breaking news online 

[ ispensary 

Did you take any time 
off work to watch the 
World Cup? 

"No, I didn't take any time off work 
as I am not interested, and none of 
my staff took any time off either." 
Kaushik Patel, Jaywick Pharmacy, 
Clacton-on-Sea, Essex 

"I am sure people did watch the 
World Cup but no one took any time 
off. I just don't think people were 
that interested." 

Ceri Evans, Rowlands Pharmacy, 
Kettlethorpe, Wakefield 

No - II am not fussed about 
football 77% 


Yes - 1 took up my employer's 
offer of flexible working to watch 
some games r <■ 

Yes - 1 took holiday so 1 didn't 
miss some matches 22% 

Armchair view: Over three quarters 
of pharmacists were not fussed 
about the World Cup, however one 
in five booked time off work so they 
would not miss key games. Despite 
some employers offering flexible 
working during the tournament, only 
2 per cent took it up. 
Next week's question: 
Will the white paper be good or bad 
for community pharmacy? Vote at 

Dispense clopidogrel 
off licence, PCTs advise 

East Yorkshire pharmacists told to change policy to save cash 

Chris Chapman 

Yorkshire PCTs have told 
pharmacists it is acceptable to 
dispense generically prescribed 
clopidogrel after Lloydspharmacy 
instructed pharmacists to query 
prescriptions potentially using the 
drug off licence. 

Lloydspharmacy had told 
pharmacists to question all 
prescriptions for clopidogrel in 
combination with low-dose 
aspirin and return for amendment 
unless the brand Plavix or the 
generic hydrogen sulphate salt 
was specified. 

Although generic clopidogrel is 

licensed for all applications in the 
EU, in the UK a patent prevents 
generic clopidogrel hydrochloride or 
besilate being licensed for the 
prevention of atherothrombotic 
events in patients with acute 
coronary syndrome. 

However, medicines management 
teams from NHS Hull and NHS East 
Riding of Yorkshire wrote to all 
pharmacists in East Yorkshire, 
advising them to end the policy. 
The generics' balance of efficacy 
and safety made it "reasonable" 
to use the products off label, the 
PCTs countered. 

"It is likely that the cost of generic 
clopidogrel will become significantly 
lower than the branded product over 

the next few months and the 
potential savings on the drugs bill 
for both pharmacy and secondary 
care will be significant," the PCT 
letter added. 

Lloydspharmacy superintendent 
Steve Howard said the multiple had 
acted in line with RPSCB guidance 
to ensure prescribers were aware the 
medicine was being used off licence, 
and seek approval so the right 
product could be supplied. 

"Many primary care organisations 
have stated that it is acceptable to 
supply [clopidogrel] against all 
prescriptions and where we have 
been informed this is the case the 
information has been passed to 
pharmacies," Mr Howard said 

First community automated 
dispensing machine ready to go 

The first automated dispensing 
machine in a UK community 
pharmacy is ready to go live once 
laws are clarified, C+D can reveal. 

The machine, which is installed in 
Primary Care Pharmacy Nuneaton, 
is fully operational but not in use 
due to questions over supervision 
laws, which require a responsible 
pharmacist to be in charge of 
every pharmacy. 

The machine, installed by robot 
companies ARX and Rowa, would 
allow pharmacists to dispense 
prescriptions out of hours. 

Customers are given a pin code to 
access the pharmacy's foyer, where 
they are able to speak to a 
pharmacist via a video link. The 
pharmacist can then dispense the 
medicine via the pharmacy's robot. 

MHRA licenses 

Botox can now be used as a 
preventative treatment for 
headaches in chronic migraine, 
following approval from the MHRA. 

The botulinum toxin injection, 
which is usually associated with 
cosmetic surgery, received the 
licence extension after being shown 
to reduce the frequency of episodes 

The automated dispensing machine at 
Primary Care Pharmacy, Nuneaton 

ARX spokesman Luke Lowles- 
Hourigan said the company was 
"close" to piloting the new system. 

in patients who experience 
headaches on at least 15 days per 
month, of which at least eight days 
are with migraine. 

The news follows the results of 
the PREEMPT trial, which found 
patients receiving 31 Botox 
injections into seven specific head 
and neck muscles, with an additional 

"It's functional... but it's still a grey 
area for the law," he added 

Michael Burr, of Primary Care 
Pharmacy, said the pharmacy 
was also considering using the 
automated dispensing machine to 
dispense repeat prescriptions. 

Last month PharmaTrust 
announced its intention to pilot 
automated dispensing machines 
in hospital pharmacies, rolling 
out to community premises by 
late 2011. CC 

Prepared for the health 
problems of returning 
World Cup travellers? 

See our 10-point guide on p15 

eight injections to relieve specific 
pain, experienced significantly fewer 
days with headache than those 
treated with placebo. 

Botox is also currently licensed fo 
blepharospasm, hemifacial spasm, 
cervical dystonia, excessive armpit 
sweating, cerebral palsy and upper 
limb spasticity. CC 

Botox to treat chronic migraine 

8 Chemist Druggist 1 7.07.1 

fl new POm to P' solution for heartburn 



Pantoloc Control is a new OTC treatment for the burning problem of acid 
reflux. Containing pantoprazole 20mg, this new l POM-to-P' switched 

medicine can be recommended as a first choice treatment for 
frequent sufferers experiencing two or more episodes 
of heartburn or acid regurgitation a week. 

Between 10-20 per cent of people in the UK experience acid reflux at least 
weekly,' and it can impact on quality of life, leading to avoidance of certain 
foods and drinks, and loss of sleep. 

Some 80 per cent of regular heartburn sufferers complain of night-time 
heartburn. Over 70 per cent of these people take OTC medicines for relief, but 
less than a third consider them to be 'extremely effective'. 1 ' 
NICE Guidelines- recommend that for many patients self-treatment with antacid 
and/or alginate therapy may be appropriate for immediate symptom relief. However, 
additional therapy is appropriate to manage symptoms that persistently affect quality of life. 

As a new and effective OTC treatment that stops stomach acid secretion at source, Pantoloc 
Control offers more complete and sustained relief from acid reflux symptoms than other OTC 
treatments such as antacids and H2 antagonists. 

Give your customers the benefits of Pantoloc Control 

For short term treatment of reflux symptoms such as heartburn and acid regurgitation 

Can be used for up to 28 days' treatment 

For adults over 18 (not pregnant or breastfeeding women) 

Long duration of action - one tablet gives up to 24-hour acid suppression, 

providing day and night symptom relief 

Effective - gives complete symptom relief in 70 per cent of sufferers after seven days 4 
Provides sustained relief, but not immediate relief - treatment for 2-3 consecutive 
days may be necessary to improve symptoms 

Well established safety profile. Some 5 per cent of patients may experience ADRs - 
diarrhoea and headache are most common 

The parietal cells in the stomach produce gastric acid, and can secrete up to two litres a day. Proton pumps in the parietal cells 
are responsible for the final step of acid production. Pantoprazole binds irreversibly to proton pumps, thus suppressing acid 
production 'at source'. This raises the pH of the stomach contents and reduces the 
severity of heartburn. 

Normally triggers such as the sight and smell of food lead to 
the activation of proton pumps. Such triggers cause nervous 
and/or hormonal stimuli, leading to production of histamine, 
acetylcholine or gastrin, that 'switch on' proton pumps. 

H2 antagonists reduce acid secretion by blocking histamine 
receptors, and have no effect on other stimuli. They therefore 
inhibit acid production to a lesser extent than PPIs such as 

Antacids neutralise acid in the stomach and have no 
inhibitory effect on acid secretion at all. They only provide short 
term relief from the symptoms of heartburn, rather than tackling 
the cause. 

20 mg g as , tr 



20 me 



References: 1 . Dent J, El-Serag HB et al. Gut 2005; 54: 710-71 7 2. Shaker R, Castell DO et al. Am J Gastroenterol 2003; 98: 1 487-1 493 3. NICE Clinical Guideline no 1 7. Dyspepsia - management of 
dyspepsia in adults in primary care 4. EMEA. Assessment report for Pantoloc Control 2009. Doc ref EMEA/374696/2009 
Pantoloc Control® 20mg gastro-resistant tablets 

Presentation: Yellow tablets containing 20mg pantoprazole (as sodium sesquihydrate). Indications: Short term treatment of reflux symptoms (e.g. heartburn, acid regurgitation) in adults. Dosage and 
Administration: Adults (including elderly) one tablet daily. Children under 18 years: not recommended. Treatment may be necessary for 2 to 3 consecutive days to achieve symptom improvement. If no 
symptom relief within 2 weeks consult a doctor. Treatment should not exceed 4 weeks without consulting doctor. Contraindications: Hypersensitivity to active, to soya or any of excipients. Co-administration 
with atazanavir. Precautions: patients should consult doctor in cases of: unintentional weight loss, anaemia, Gl bleeding, dysphagia, persistent vomiting, vomiting with blood, previous Gl ulcer or Gl surgery, 
symptomatic treatment more than 4 weeks, jaundice, hepatic impairment, liver disease, over 55 years, recently changed symptoms, serious disease affecting general well-being Interactions: possible reduced 
absorption of actives whose bioavailability is pH dependent (eg ketoconazole); reduced bioavailability of atazanavir. As pantoprazole is metabolised by cytochrome P450 enzyme systems possible interactions 
with substances metabolised by same enzyme system cannot be excluded. Pregnancy & Lactation: not recommended. Side Effects: Uncommon: headache; dizziness; diarrhoea; nausea/vomiting; abdominal 
distension, bloating, pain and discomfort; constipation; dry mouth; rash, exanthema, eruption; pruritus; asthenia, fatigue and malaise; sleep disorders, raised liver enzymes. Rare: disturbances/blurring of vision; 
urticaria; angioedema; arthralgia; myalgia; hyperlipidaemias and lipid increases; weight changes; raised body temperature; peripheral oedema; hypersensitivity reactions; bilirubin increased; depression. Very 
rare; thrombocytopenia; leucopenia; disorientation. Frequency not known: interstitial nephritis; Stevens-Johnson syndrome; Lyell syndrome; erythema multiforme; photosensitivity; hyponatraemia; jaundice; 
hepatocellular injury/failure; hallucination, confusion. Legal Category: P. RRP: 7 tablets: £6.90; 1 4 tablets: £1 1 .90. Marketing Authorisation No: EU/1 /09/51 9/001 -004 MA Holder: Nycomed GmbH, Byk- 
Gulden-Str.2, D-78467 Konstanz, Germany Date of Preparation: February 201 0. Further information is available from Novartis Consumer Health, Wimblehurst Road, Horsham, RH1 2 5AB, UK. 
Please refer to SPC for full prescribing information. 


CE for counter staff - satisfy your PCT audit with Counterpart 

Retail talk 

Should higher SPF sun 
cream cost the same 
as lower factors? 


because it 
people to 
use the 
factors. We 
know from 
that if 

customers look along and see 
that the lower factor's cheaper, 
they'll take the cheaper one. I have 
had people saying, 'I know I should 
have that one but I'll take this as 
it's cheaper'." 

Alison Gibb, The Co-operative 
Pharmacy, Alness, Ross-shire 

"I would think 
so, yes, 
otherwise, it 
might lead to 
use. The 
might need a 
higher factor but think, Til risk it and 
see how it goes', so I think they 
should all be priced the same." 
Pradeep Prabhu, Murrays 
Healthcare, Halesowen, 
West Midlands 


N »j 

v •• - ■ . • Pharmacists are 
overwhelmingly in favour of a move 
to standardise the cost of sunscreen 
across the different protection 
factors. This reflects Superdrug's 
recent promise not to charge more 
for high SPFs. 
Next week's question: 
Do you think a rise in VAT to 20 per 
cent will adversely affect your 
pharmacy's sales? Vote at 

Gapitalise on. the 
incontinence market - 
£63.9m and growing 

See category focus, page 19 

GSK £3m campaign backs launch of 
fast-acting desensitising toothpaste 

GSK Consumer 
Healthcare has 
announced the 
launch of 
Sensodyne Rapid 
Relief, a fast-acting, 
desensitising toothpaste. 

The launch will be supported by a 
£3 million integrated marketing 

A television advertisement depicts 
a variety of people discussing how 
they avoid the pain of sensitivity 
when confronted with an ice cream 
or an iced drink. The campaign 
also includes print advertisements, 

activity and PR. 

Prices: £2.45/45ml; £3.65/75ml; 

Pip codes: See C+D Monthly Price 
List or 
GSK Consumer Healthcare 

Canesten launches online 
resource for professionals 


TifvCa ?t<k\$, or 

The Canesten 
brand has 
launched an 
online resource 
on fungal 
aimed at 
and other 


The website,, has been 
designed to enhance knowledge of 
the most common fungal infections 
and their treatment, says Canesten 
manufacturer Bayer Consumer Care. 

Conditions covered on the website 
include vaginal thrush, cystitis, 

athlete's foot, 
sweat rash, 
ringworm and 
jock itch. 

available on 
the website 
diagnosis and 

algorithms, patient information 
leaflets and an image library, 
according to the company. 

Ceuta Healthcare 

Tel: 01202 780558 

Jungle Formula: All areas 
Lanacane Anti Chafing Gel: All areas 
Magicool: CMTV, ITV, five 
Magicool Plus: GMTV, ITV, five 
OdorEaters: All areas 
Panadol: All areas 
Savlon: All areas 
Seabond: All areas 

PharmaSite for next week: Zirtek - windows, Zirtek- in-store, 
Zirtek - dispensary 

A-Anglia, B-Border, C-Central, C4-Channel 4, five-Channel 5, CAR-Carlton, 
CTV-Channel Islands, C-Granada, GMTV-Breakfast Television, GTV-Grampian, 
HTV- Wales & West, LWT-London Weekend, M-Meridian, Sat-Satellite, STV- 
Scotland (central), TT-Tyne Tees, U-Ulster, W-Westcountry, Y-Yorkshire 

Market focus 

• The global oral hygiene 
market is forecast to re 
$29.5 billion by 2013. 

• Toothpaste sales domi 
the global oral hygiene 
market, generating 57 per ce 
of its revenue. 

Source: Datamonitor, November 

Tel: 0845 762 6637 

Pantoloc is 
on the TV 

Pantoloc Control heartburn 
treatment is the focus of a television 
campaign from this month. 

The advertisement is running 
on ITV, Channel 4, five and Sky 
channels, says manufacturer 
Novartis Consumer Health. 

The campaign will be supported 
by a series of press adverts in 
national women's lifestyle 
magazines throughout 2010. 

In addition, a PR campaign will rur 
during the summer months. 

A comprehensive POM to P 
training programme to support 
pharmacy staff has been rolled out 
nationwide, adds the company. 

Novartis Consumer Health 
Tel: 01403 218111 

Lynx channels 
Top Gun in ads 

Lynx Dry+ Sensitive deodorant is set 
to be the focus of a £4 million 
marketing campaign this summer, j 
featuring a Top Gun-inspired advert, 
manufacturer Unilever UK has 

The multimedia campaign will 
include video-on-demand, cinema, 
digital, in-store, sampling, PR and 
outdoor advertising. 

Lynx Dry+ Sensitive tackles both 
sweat and sensitive skin, says 
Unilever UK. 

Unilever UK 

Tel: 01372 945000 

Chemist'- Druggist 17.07.10 

PIP Code 

1 15-2917 

50 50650 071016 


Abbrevioled Prescribing Information ftoczolumide/fimolol 20/5 mg/ml Eye Diofi\ Solution Presentation: One millilitie il olul 

of doizolumuie («s hydfodilofide) ond 5 mg ol limolol (us maleote) Uses: footmen) ot etevoted iritiu-nrulnr ptesswe in polienls with opeiMtngre glaucoma w 
pseudoexfoliatrve gloiHoma when lopicol beto-Wockei monotherapy is not sufficient Dosoge: Adull: One drop in the (coniunctwcH sac ol the) effected eye{s) 
hw limes dmty Child: Effkocy hos not been established Sofety m polienls below the age ol two years bus nut been established it onolhei lopitol fiphihulunr 
agent is being used ihe two preparations should be administered ol least len minutes opart Contro-indtcotions: Hypetsensilivily to me active substances oi 
to any ol the eiapienls Reactive oaway disense incfuding broflchiol asthma m seveie ihmrm obstructive puimonory disease Sinus bradycardia, second- oi 
tnirddefliee aliioverrtnculoi block, overt cardial failure, tordiogerw shocfi Seveie ienol tmpaiiment oi hypeicbloraemK acidosis Special warnings and 
precautions: Ibis medicinal product mny lie ohsorbed systemitoHy II signs ol serious reactions oi hypersensitivity occur, discontinue use Constdei discoolrnumg 
il local ocular adverse reactions occur Ihe some rypes ol odveise reactions luund with syslemii odministrolron ol beto-Mockers or sulphonoimdes may occur with 
ocular use This includes worsening ol Prinzmetal's angina, worsening ol severe peripheral ond control circutotory disorders, ond hypotension Cardiac failure 
should be adequately controlled before beginning iberopy Wulih For signs of cardioi failure should and (hrscfi pulse rotes in patients with a history ol severe 
cocdioi drseose Respuolory reactions and cordmi reactions, including death due lo bronchosposai in potients mm asthma and rarefy deoili in associalnn with 
cmdiac loiiure, hove been leported following administration ol timolol rnafeote Use with motion in patients with bepaw tmpoumenl because its use in such 

polienls bus not been studied Wlule taking (Uwclcers, patients with a history of ulupy oi severe cmophytoctM reaction 10 u variety oi odergens y be more 

reactive lo occidental, (hogrtostk, nr therapeutic repeated thoBenge with stub ollecgens lliese pntienls nioy be unresponsive tu the usonl doses ol epinephrine 
used to lieoi onnphylactic reoctiorrs Concomitant tbeiopy with dorzotomide, oral corbomi onhydrose inhibitors ond lopkol bettwdreneigK blocking ogents is noi 
recommended Tientmenl withdmwul should he done gradually in patient with coronary head disease Betabfockeis mny musk cerlorn symptoms ol 
hypoglyioemio in patients with diabetes inelhtus or hypoglycemia Ihey mny most leitom symptoms ol hyperthyroidism nod obrupt wtlhdrowal may prctipitole 
a worsening ol symptoms. fletoWoclers mny aggmvnie symptoms oi myasthenia giuvis Patients with a poor history ol renal iuIcuIi mny be al increased nsl 
ol uiobihiosis while using this product Ihe use of doizolnmide/innolul bus noi been studied in polienls with mole angle-closure gjoucoma Topical dorzolomide 

should be used with caution in patients with pre-exisling cl i corneal defects ond/oi a history of iittro-oculoi suigeiy Choroidal detachment concontitcin! with 

ocular hypotony hove been cepoited oftei liltmhon procedures with administration ol ogueous suppressunl themjiies Diminished lesponsivenev, lo oplithulmu 
timolol mulente after prolonged therapy hos been reported in some patients Contours benzaikonwm (blonde, whuh mny muse eye irriiation Contact lenses 
should he removed prior to opptkatiofl unci oi least 15 minutes sliould have passed before reinsertion Benrolonram <hlonde is known lo dmofout soli contact 
lenses Interactions: Spectfk inleroclion studies hove noi been performed Potentiated syslemii beta-blockade hos been leported during combined treotmenl 
vrith quimdme ood timolol Dar/nlamirfp is a corbonk onhydrose inlnbiloi ond, although ophthalrrw solution has ml been Found to cause actd-bose disturbances, 
ihese disturbances have been repotted with oral coibonii onhydrose inhibitors ond have in some instances, resulted m intetoclions The potential for such 
interactions should be considered Mydriasis resulting hum concomilont use ol ophlhalmN limolol mulente and epinephrine hos been reported occasionally 
Beta-bloc Iter; may increose the hypoojy^oemk effect of uniidioheiii agents ond may exacerbate the rebound hypertension which ton follow the withdrawal ol 

ctotuom In clinkoi studies, doiznlaroide/limolnl eras used (oncormluntiy with the following products without evidence of odveise interactions ACE ■inhibitors, 
culiium channel bloileis, diuietns, nun-sleroidol iinlwiiflommolory aciive subslonies including oielylsuhiyhi amj, ood hormones (eg oestrogen, insulin, 
Ihyiomne). Ihe potential exists h udihtrve effects ood piuduciion of hypotension uod/ur marked hrodyionhu when timolol is odimnrsleied together with oral 
calcium chonael brockets, cotKhowniinedepletmg substances or beto-ndieneign blue ling agents, ooliorrhyihnncs (including amiodomoe). digitalis glycosides, 
porosvnipothoimmeftcs, narcotics, urn! monoamine oxidase (MAO) inhibitors Pregnancy and lactation: Should noi he used during pregnancy oi loctoriofl 
Driving ond operating machinery Possible odveise leaclions such os blurted visum may aKecl some patients' utility to dove ond/oi operate machinery Side 
effects: Fbe following odveise reactions have been reported with the fixed combination of dmzolumule ond timolo! oi one ol ils components either during tlmkol 
studies oi duung post-motketing experience systemic lupus eiylhemotosus, heodoche, dizziness insomnia; memory loss, poraesthesio, increase in signs oad 
symptoms o| myasthenia grows, cerebrovascular Occident; depression, nightmares, decreased libido, oculai dryness, irritotion (Wephorilis, keratitis), itching, 
burning, stinging, pom ond leafing, conjunctival infection, visual disturbonces including refractive changes unci blurred vision, corneal sensrtwrty decreased, oedema 
and erosion, eyelid intlommofion, urilolmn and ciuslmg, irnloiyr litis, tinnsienl mynpio, omlur hypotony, 'lioronJol deliKhriienl {following filiation surgery), ptosis, 
diptopn; tmrntus; bradyctttdia; syncope, potpHalion; oedema, oirhyrbmw, lieoct blur I, cacdim onest, hypotension, 'hest pom. coogestive heart failure, cerebral 
iscnoemio, cfaudkanan: Raynaud's phenomenon, culd bonds ond ieei, sinusitis, shortness ol breath; lespiialory lomjie, rhinitis, epntaiis, dyspnoea, (Kowhosposm, 
inuyh, taste perversion; museo, Ibrool miration, diy mouth, nausea, dyspepsia, dionhoeo, contact cieimolitts. lash, alupeno, psoriasitoim msh oi exoieibolioa 
ol psunosis, urolilhiosis, Peyiome's disease, syslemii nUergk reactions, Including wigioedemo, urtKorio, pruritus, rash, onophyloxis, rarely bronchospasm, 
osthenio/fotigue Pack sizes/cost (exct. VAT): V" 10.05 pei unit legal category: POM MA Holder: Sand02 Ltd, 37 Woolmei Woy, 8ordon, Hampshire, 
GU35 90E MA No.: PI 04416/0705 Lost revision of text: 16/01/2010 Please (onsub* the Summary of Producl ChoractensiKs for Further information 
before prescribing Ref: 70S Of) I vl 

Adverse events should be reporled. Reporting forms and Information con be found al Adverse events 
should also be reported to Sondoi ltd, + 44 (0)1276 698020 or 

Ref: ;ii [ .[J04vl luly 7010 


A healthy decision 


Get the industry verdict on the white paper 

Vive la white paper revolution? 

Andrew Lansley revealed a radical shake-up in the Liberating the NHS 
white paper this week. Max Gosney asks if pharmacy is bound for 
triumph or tragedy in the new health republic? 

Uncontrollable fist pumping and 
groans of despair. It's easy to 
imagine how CPs and PCTs reacted 
to this week's health white paper. 
For pharmacists though, the instant 
reaction to the new government's 
health vision is less clear cut. 

Health secretary Andrew Lansley 
has laid out a radical reform 
programme in the Liberating the 
NHS white paper. Out go red tape, 
obsessions over targets and political 
micro management. In come greater 
patient powers, more qualitative 
measures and frontline NHS staff 
empowered to take decisions. Those 
are the driving themes of the paper, 
but it's their application to 
commissioning that will be of most 
interest to pharmacists. 

The standout reform from this 
paper is the decision to cull all PCTs. 
Trusts will disappear from 2013, 
with functions taken on by local 
GP consortia, a new NHS 
commissioning board and local 
authorities. Few in pharmacy will 
grieve the departure of their local 
PCT, contractor representatives told 
C+D this week. 

"From a personal perspective, 
good luck and good riddance," says 
Hiten Patel, MD at PharmaPlus 
"They haven't engaged with 
community pharmacy. They've got 
too big and one department never 
talked to the other." 

Celebrating the demise of trusts 
could be premature, according to 
Rob Darracott, chief executive of the 
CCA. Expect one final sting in the tail 
as PCTs prepare to disband, he says. 
"Changes like that take place over a 
12 to 18 month period. During that 
time they're more concerned about 
preserving the job they have rather 
than the job they have to do. During 
a major reorganisation there can be 
a loss of focus." 

The passing of PCTs will 
undoubtedly disrupt pharmacy at a 
local level. But nationally there are 
also massive ramifications from 
their departure. The global sum - 
pharmacy's bread and butter funding 
- has sat with PCTs since April this 
year. Industry insiders suggest the 
pharmacy pot is likely to pass on to 
the new NHS Commissioning Board 

easons to be 

set out in the white paper. But for 
now it remains a going concern. 

The other grey area is the 
future of pharmaceutical needs 
assessments. These task PCTs with 
mapping out local pharmacy services 
and using the data to determine new 
contract applications and inform 
commissioning. Whether the 
documents due to come into force 
from 2011 will be lost amid the 
blood letting to come remains an 
unanswered question. 

The government says this 
white paper is driven by a desire to 
shift decision-making as close as 
possible to patients. And what's 
clear is CPs seem to be the 
government's favoured generals. 
CP consortia will inherit an 
£80 billion commissioning 
budget and form 500 hubs for 
directing local NHS services. 

For pharmacists, a gut feeling of a 

CP whitewash on commissioning is 
perhaps the most natural reaction to 
this initiative. But there are caveats. 
Mr Lansley has gone on record to 
stress that CPs will not have a 
monopoly on consortia. The forums 
will be made up of several different 
clinicians, including pharmacists. 

In fact the consortia are an 
opportunity rather than a threat, 
says Steve Foster, superintendent of 
Pierremont Pharmacy in Broadstairs, 
Kent. "PCTs have been a mess so 
their going is not a bad thing. Putting 
decision-making in the hands of 
clinicians is a positive move." 

CPs will not run away with the 
format, adds Mr Foster, who also 
heads the Health Care Professionals 
Commissioning Network, which 
was set up to broaden NHS 
commissioning expertise beyond 
GPs. "I think there's a very strong 
message from the top down that 

GPs can't do this alone. If it's their 
own money on the line they'll be 
keen to find the most cost, effective 
way of doing things. And pharmacy 
can offer that service." A formal 
incentive between the two 
professions is also a likely 
development, the CCA predicts. 

Further reassurance for pharmacy 
comes in the white paper's 
commitment that its services won't 
rest solely with GP consortia. The 
NHS Commissioning Board will 
oversee pharmacy services, the 
document stresses. Consortia are 
likely to have input though. And the 1 
jurisdiction over enhanced service 
commissioning is anyone's guess. 

"It will be interesting to see where )|| 
the commissioning of enhanced 
services will fall," says Jane Moffatt, 
head of medicines management at 
Brighton and Hove City PCT. "I see 
the responsibility sitting with GP 

Others feel enhanced services 
might migrate to local authorities, 
which will take on responsibility for 
public health. "Enhanced services 
would sit under public health with 
the local authorities," Mr Darracott 
told C+D. "It's unclear at this point. 
We're back to waiting for what the 
detail is." 

That lack of detail was one major 
criticism of this white paper from 
within government, according to 
Whitehall insiders. The document - 
61 pages compared to 141 for the 
pharmacy white paper of 2008 - is a 
mission statement rather than an 
instruction manual. The gaps will be 
filled in a plethora of consultations 
in the future. 

For now, Andrew Lansley's white 
paper remains a distinct shade of 
grey for pharmacy. 


12 Chemist+Druegist 17.07.10 

What's your verdict on 
the health white paper? 

Join the debate in C+D's 
Linkedin group at - search 
for Chemist and Druggist - 
or email your views to 

What do you think? 


Making the best decisions - do the maths 


I like to think of myself as an advocate for the 
profession. Pharmacy has been good to me - as 
much as any demanding, uncertain, stressful 
profession can be - so I agreed to be shadowed by 
an A level student thinking through career options. 

We got to discussing patient information 
leaflets, and I smiled at her confusion as I 
explained how lists of side effects stopped many 
people taking the medication they needed. 
"That's silly" she said, "Why don't they do what's 
for the best?" Ah - the simplicity and innocence 
of youth. 

Despite the 'Broken Britain' image of insolent 
teenagers portrayed by the press, we do tend to 
believe and obey those who are senior to us in 
position and age But part of the maturing process 
sometimes moves us from testing and challenging 
the world in a healthy way to cynicism and doubt. 
"I don't want the cheap generic - they're not as 
good as the brand!" "I don't need the cream as 
well as the pessary - you're just trying to make 
more money!" "Why is it out of stock - has it 
been withdrawn?" 

It's hard to gauge risk and probability, which is 
why at odds of 14 million to one we're still 
prepared to chuck a pound away on the National 
Lottery for the possibility of a large benefit from a 
small outlay. Hey, even I'm prepared to gamble £4 
a week on the PLB actually making a beneficial 
difference to my working life. 

So we fear our teenagers will do drugs, when 
they're 20 times more likely to die from alcohol 
abuse, and every time there is a health scare more 
people are harmed by lack of treatment - as we 
saw with the MMR panic 

And what hope when even scientists don't 
support what is in the health interest of the 
nation 7 I was appalled to read that the majority 
responding to last week's C+D poll would not 
accept the swine flu vaccination when the risk 
benefit ratio means we should jump at the offer. 

So how can we overcome the perception 
problem? It seems medical fears are like the Lotto 
in reverse, promising £1 a week for life, but with a 
14 million to one risk of losing a fortune. 

Today I told a man that his 10-year 
cardiovascular risk was 20 per cent, and that to 
take his antihypertensives could reduce that by a 
quarter. "So they're only helping five people in a 
hundred?" he asked. "No. Well, yes, in a way, 
but..." and I floundered to justify what should be 
such a simple choice, wanting to shout: "I KNOW 

But of course I don't know what's best for him, I 
just picture the maths in a different way, and we 
all know that good health isn't just absence of 
disease. That's the problem with concordance - it's 
not about what's the right thing to do, but about 
our right to decide what's for the best. 

Building relationships in a time of change 

I write this prior to the publication of 
the coalition government's NHS 
white paper, but I have a strong 
sense that even after the details 
emerge there will still be more 
questions than answers 

I am sure pharmacists across 
England will agree with Mr Lansley 
that CPs, who are responsible for the 
majority of NHS spend, should be 
fully engaged in decisions about 
how patient services can be made 
more responsive and more cost 
effective. We know however that 
many GPs will not welcome the 
financial risk and the managerial 
burden of managing budgets that 
this will bring. 

In the meantime, we need 
to understand how pharmacists 
can become involved in new 
commissioning consortia and help 
shape new models of integrated 
care. Will the new regime impact the 
way pharmacy is funded, the 
construction of the pharmacy 
contract and the global sum? Will 
the principle of rewarding outcomes 

be applied to the profession? That 
would change everything. 

At Lloydspharmacy we are already 
considering how we can be more 
flexible in our approach to local 
healthcare issues. Equally, I predict 
that flexibility will be required at 
LPC level. To date they have been 
the profession's interface with PCTs. 
Can they now adapt to also deal 
with the new local commissioners 7 

I also wonder whether, since the 
focus of GP commissioning will 
inevitably be secondary care services, 
the time has arrived for pharmacy to 
step forward and demonstrate the 
role it can play in keeping people 
out of the expensive bits of the 
healthcare system in the first place? 

As a pharmacist I know exactly 
what potential lies within our 
profession. With our ready-made 
accessible healthcare network, our 
colleagues in general practice should 
be looking to pharmacy to support 
new local commissioning and we in 
turn should build these relationships 
and get involved 

Ask yourself this. Do we represent 
a viable option for them to 
commission services from? Can we 
support the new NHS? One thing is 
clear - we must adapt as a 
profession. Whether we like it or 
not, our role has evolved into a 
commoditised function. Our future 
lies in our powerful customer- 
pharmacist relationships, our vast 
healthcare expertise, our ability to 
add value to patients' health and to 
improve their quality of life. You do it 
every day. We don't document it. 
This will change. 

Whatever the future holds and 
however deep the uncertainties, 
pharmacy should be a full and 
willing partner in the new NHS 
Never before has the profession had 
such opportunities to come in from 
the margins of healthcare and forge 
partnerships with other clinicians to 
improve the health of the 
communities they serve. 
Roman Brett, head of professional 
and external relations, 



Lst+Druggist 13 

Send your views and letters to 

I believe pharmacists 
should become elitist 


Why pharmacists 
need to be elitist: 
the stats 

In 2008 there was a 13 per 
cent vacancy rate for hospital 

25 per cent of NHS pre-regs 
never take up a permanent 
position with the NHS. 

In 2002, MORI classed 
pharmacy as a 'non manual' 
profession, alongside 
technicians, salesmen and clerks. 

As of 2006, 87 per cent of 
patients stated they would 
prefer to receive information 
about medicines from a CP than 
a pharmacist. 

14 17.07.10 

Elitism may sound like an unsuitable 
characteristic for a pharmacist, but 
what does this mean? In my opinion, 
it means that pharmacists should 
not believe themselves to be, nor be 
perceived as, second rate healthcare 
professionals, behind doctors and 
dentists, but rather their equals. It 
means that pharmacy students 
should feel enthused about the 
journey they are about to embark 
on. It means newly qualified 
pharmacists should want to stay in 
the profession. 

This elitist attitude starts with the 
pharmacy education system. Having 
recently been through this system 
myself, it is clear that many students 
lose their attraction to the 
profession during their studies. 

The development of an MPharm 
degree is no easy task, as pharmacy 
encompasses so many different 
areas. The majority of MPharm 
courses attempt to strike a balance 
between the fundamental sciences 
and the practice elements of the 
profession. However, a recent study 
by Wilson et al showed that less 
than 30 per cent of students 
considered science-based practicals 
useful. Compare this to the 92 per 
cent of students who thought that 
dispensing practice was of benefit to 
them and you can see where 
attitudes begin to change. If 
students were more aware of what 
they could potentially do as a 
pharmacist then the science/practice 
balance could be somewhat restored. 

Institutions need to do their part 
in promoting the multitude of diverse 
careers that pharmacists can follow. 
The roles which pharmacists can take 
up are numerous, yet to the average 
pharmacy graduate remain unknown. 

Opportunities such as working in 
public health for the World Health 
Organization or as a biotechnologist 
for the ministry of defence are all 
available to pharmacists due to their 
broad skill base. Even the traditional 
roles of community, hospital and 
industrial pharmacy have diverse 
ranges that are not promoted 
successfully during undergraduate 
studies. Are we not supposed to be 
creating all-rounders - graduates 

who have the transferrable skills for 
any job they choose? 

The problem is the availability of 
these opportunities. For example, in 
2006 there were only 14 industrial 
pre-reg places available. For such an 
important part of the pharmacy 
chain, is this really representative at 
pre-reg level? In this credit-crunched 
world companies will cite that pre- 
reg programmes are not a worthwhile 
investment due to training costs, etc 
but this is where our professional 
bodies and the Association of British 
Pharmaceutical Industry must step 
in and promote the potential career 
paths for pharmacists in industry. 

Pre-registration programmes in 
hospital, on the other hand, are 
widely promoted and available. 
Hospital pharmacists play a key role 
in ensuring hospital healthcare is 
provided effectively and efficiently, 
yet why is this role not rewarded? 
Agenda for Change was meant to 
provide better rewards for 
pharmacists yet why is there not the 
parity with doctors and dentists, 
which was the intention in the first 
place? On what basis were both the 
medical and dental professions 
allowed to opt out of the scheme 
whereas pharmacists had to stay? 
Our role is just as important in the 
functioning of the NHS as doctors 
and dentists so the rewards should 
be of a similar ilk. 

Community pharmacy has a 
stigma attached to it that needs to 
be shifted. Many patients are not 
aware of the skills that a pharmacist 
possesses; equally pharmacists are 
not given opportunities to showcase 
these skills. Extra services give 
pharmacists a chance to broaden 
their horizons but is enough being 
done to alter the public perception 
of the community pharmacist? 

Some patients appear surprised to 

be receiving medical advice from a 
pharmacist. Should this really be 
such a shock? Gaining the respect of 
the general public is paramount in 
not only providing an effective 
service but also creating a strong 
social healthcare network. This 
particular topic has been discussed 
over a number of years, yet we are 
still seeing the same problems come 
up time and again. It is changing, but 
is it changing fast enough? 

Many, if not all of the points I 
have raised have been covered in this 
very publication time and again. Yet, 
why are we still talking about them? 
I believe it is due to our collective 
attitude We, as a profession, need to 
realise that we truly belong at the 
centre of healthcare. In a world 
where healthcare is in a constant 
state of flux, we need to ensure that 
our profession stands up to the 
rigours of the future. Pharmacy 
should be at the core of the NHS 
and yet always appears to be on the 
periphery compared to other 
professions. This is indicative of a 
profession that has not realised its 
own importance within the 
healthcare system. 

This brings me full circle to 
elitism. Perpetuating a feeling that 
we truly belong at the centre of 
healthcare is not easy and some of 
the issues I have highlighted will 
impede that process. However, if we 
collectively strive towards solving 
these problems then we become 
inherently stronger. If we continually 
look to improve our profession then 
not only do we improve the public 
and other healthcare professionals' 
perception of us but we improve 
the perception of pharmacy for 
ourselves. That is more important 
than anything else. 
Adrian Khan is a pharmacist and 
PhD student 

Is elitism the mechanism that will put pharmacy at the centre of 
primary healthcare? To have your say on Adnan's argument or to 
submit your own opinion piece, email us at the address below. Don't 
forget to include your contact details. 



" 15 Travel health 


► 16 End of life: pt 1 

19 Incontinence 22 Coalition plans 25 First impressions 


World Cup 

With football fever now dying down (except 
n Spain), Chris Chapman explains what 
to look out for in customers returning from 
South Africa beyond vuvuzela-inflicted 
aearing loss, including conditions virtually 
non-existent in the UK 

Most travellers who have taken sensible precautions - such as 
vaccinations, avoiding contaminated drinking water and using 
protection during sexual intercourse - have a low risk of 
developing health problems on return from the World Cup. Risk 
is increased by failing to take precautions, for example not using 
condoms during sexual intercourse, or by visiting rural areas. 

Of those who do develop problems, the most common will be 
gastrointestinal upsets. Patients with traveller's diarrhoea 
should drink enough fluids, taking oral rehydration salts if 
necessary. Patients should be advised that if their diarrhoea 
becomes very frequent, very watery, contains blood or lasts 
for more than three days they should seek medical attention 
as an emergency. There have been outbreaks of cholera in 
South Africa. 

It is currently winter in the southern hemisphere. Travellers to 
South Africa are therefore at increased risk of both seasonal 
influenza and swine flu. Treatment does not vary from current 
UK recommendations. 

Sexually transmitted infections (STIs) are a significant problem 
in South Africa. Around 8 per cent of the population have 
hepatitis B, and a 2008 report by the UNAIDS/WHO working 
group estimated that around 5.4 million 15 to 49-year-olds 
in South Africa had HIV, giving a prevalence of more than 18 
per cent in this group, compared with around 0.2 per cent in 
the UK. 

Patients who are concerned they may have an STI should be 
referred for testing The current British HIV Association 
(BHIVA), British Association for Sexual Health and HIV 
(BASHH) and the British Infection Society (BIS) guidance 
recommends all patients returning from South Africa who may 
have an STI should be tested for HIV 

There is a high risk of malaria in South Africa in the low altitude 
areas near the Mozambique and Zimbabwe borders, including 
Kruger National Park, and northeast KwaZulu-Natal to as far 
south as Jozini. The risk of malaria in cities is low. However, 
malaria is the most commonly imported tropical disease into 
the UK, with 1,500 to 2,000 cases a year 

Malaria has no specific symptoms. It can include fever, 
headache and general malaise, and can be mistaken for non- 
specific viral infection or influenza. Most cases are caused by 
Plasmodium falciparum and usually present within months of 
exposure. If malaria is suspected, it is a medical emergency and 
patients should be referred to a hospital for a blood test 

In April, there was an outbreak of Rift Valley Fever in the 
provinces where England played two of their group games. The 
fever, which is transmitted by mosquitoes, has an incubation 
period of one to six days and causes influenza-like illness 
Patients usually recover in four to seven days, but 
complications can cause death in 1 per cent of cases. 

South Africa has a high incidence of tuberculosis However, the 
National Travel Health Network and Centre (NaTHNaC) says 
the risk of tuberculosis for most travellers is low. Travellers who 
suspect they have been exposed should be referred for a 
medical evaluation. 

Other diseases known to occur in South Africa also include 
rabies, hepatitis A and typhoid. There is no risk of yellow fever. 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on travel health 

REFLECT Am I confident providing travel health advice 
to customers? 

PLAN Use this article as a prompt to consider the 

areas of travel health you need to revisit. 


Attend training on or revise identified areas. 

EVALUATE Am I better able to provide customers with 
travel health advice? 









4 15 Travel health ▼ 16 End of life: pt 1 ► 19 Incontinence ► 22 Coalition plans ► 25 

First impressions 

End of life care: part 1 

The first of two articles considers options for pain control in palliative care 

Doreen Cochrane MRPharmS 

Supported by 


In 2008 the Department of Health published an 
End of Life Care Strategy to bring about a "change 
in access to care for all people approaching end of 
life". It was envisaged that improvements would 
be achieved using a systems and care pathway 
approach for commissioning and providing 
integrated services, improving co-ordination. It 
would involve workforce development to effect 
relief of suffering, enhance quality of life and 
support for patients and their families and 
encourage initiation of palliative care early in a 
patient's illness, even when he or she is still 
receiving life-prolonging treatment. It supported 
the use of the Cold Standards Framework, the 
Liverpool Care Pathway and Preferred Place of 
Care tools. However, the needs of carers and 
professionals involved in providing palliation and 
end of life care for patients with non-malignant 
disease, including neurological diseases and 
dementia, cardiovascular, renal and respiratory 
diseases, and for children and people with learning 
disabilities remain poorly supported. 

The End of Life Care in Primary Care 2009 audit 
identified improvements needed to help more 
people die in their own homes. These include 
better access to medicines, proactive planning to 
improve clinical management of complex 
problems, carer information and support, and 
hospital discharge planning and liaison. 

Pain is the most common symptom of cancer. It 
occurs in up to 90 per cent of patients with 
advanced disease and about 67 per cent of 
patients with non-malignant illness. Moderate to 
severe background (persistent) pain and 
breakthrough cancer pain (BCP) can, in most 
cases, be treated successfully with opioid 
analgesics and adjuvant drugs. Treatment or 
avoidance of the underlying cause of pain may be 
important. Psychological distress also impacts on 
pain tolerance. 

Care is needed with prescriptions for children or 
elderly patients and for those with impaired renal 
or hepatic excretion. Appropriate assessment and 
re-assessment of pain is important both at 
initiation of opioid treatment and when converting 
from one opioid to another - see the table 
opposite for equivalent doses. Dose titration 
according to pain control or adverse effects may 
be required. 

Opioid treatment is not thought to carry a 
high risk of addiction in patients suffering chronic 

pain, a point that may be worth mentioning to 
some patients who are reluctant to take such 

Morphine This potent analgesic is used in the 
treatment of moderate to severe cancer pain and 
is the standard against which other analgesics are 
compared. It can be administered by the oral 
(immediate and modified-release formulations), 
rectal and parenteral (sc, im, iv), spinal and 
epidural routes for pain management. Oral 
(Oramorph, Sevredol, Morphgesic, MSTContinus, 
MXL, Zomorph) or rectal administration leads to 
70 per cent first pass metabolism in the liver and 
metabolites are largely excreted by the kidney. 
Reduced excretion rates may lead to sedation or 
respiratory depression. A 25 per cent dose 
reduction is recommended if the patient's 
creatinine concentration is in the range 
150-300mmol per litre. With more severe renal 
impairment, dose reduction and frequency change 
is required. The side effects of euphoria or 
dysphoria and itching are also common. 

The RPSCB Practice Committee does not 
recommend routine brand-name prescribing of 
modified-release morphine but states that 
pharmacists should take steps to prevent the 
unintentional change of the brand supplied to 

Diamorphine Diamorphine is about twice as 
potent as morphine. It is available in powder form 
for reconstitution and is essentially a pro-drug - 
it is activated by deacetylation to morphine. It 
has a faster onset of action than morphine and 
a shorter duration of action, especially when 
administered intravenously. Diamorphine 
injection is usually included in 'Just in Case' boxes 
for anticipatory end of life care. 
Oxycodone Oxycodone is about twice as potent 
as morphine. When taken orally it undergoes first- 
pass metabolism in the liver (50 per cent). It is 
slightly less sedating than morphine and is 
available as normal release (OxyNorm capsules 
and liquid), sustained release (Oxycontin) and a 
parenteral formulation (OxyNorm). It is also 
available in the compound preparation Targinact 
(see p16). The manufacturers of oxycodone advise 
against its use in patients with severe renal failure. 
Fentanyl Fentanyl is about 100 times more 
potent than morphine. It is usually administered 
from a transdermal patch delivery system 
(Durogesic DTrans, Fentalis, Matrifen, Mezolar, 
Osmanil, Victanyl). The transdermal preparation is ( 
available in a reservoir (Durogesic) or matrix 
formulation and provides 72 hours of potent 

16 Chemist -Druggist 17.07.10 

Sign up for the clinical newsletters 

analgesia. Reservoir patches of fentanyl should 
never be cut to deliver a smaller dose because this 
disrupts the drug-release mechanism. A patch 
releasing 12mcg per hour of fentanyl allows for 
greater ease of titration, especially for patients for 
whom side effects may be problematic. 

The RPSCB Practice Committee has advised there 
is no evidence of a difference in the rate of delivery 
of fentanyl patches of different brands when used 
in accordance with the product licence. However, 
manufacturers advise against brand changes and 
recommend counselling to ensure the patient and 
carers understand the reasons if such changes 
become necessary. Parenteral administration of 
fentanyl is generally only used when close 
continual clinical monitoring is available. 

It is important to counsel patients and caregivers 
about side effects associated with use of opioids. 
Nausea and vomiting occur in about two thirds of 
patients starting opioids and last for up to seven 
days; these side effects are uncommon when the 
opioid dose is stable. An anti-emetic may be 
prescribed at initiation of opioid prescribing. 
Sedation is a common side effect occurring 
usually in the first five to seven days of treatment 
and may affect some patients' ability to drive. 

Constipation is a very common and persistent 
effect of oral opioids, occurring in up to 90 per cent 
of patients. Treatment for opioid-induced bowel 
dysfunction will be reviewed next week in the 
second Update article in this series. Prophylactic 
laxatives should be prescribed on an individual 
basis for patients starting long-term opioids. 

Two new medicines containing opioid 
antagonists have been introduced. These are 
subcutaneous methylnaltrexone (Relistor) and a 
combination product containing oxycodone and 
nalaxone (Targinact), in a ratio of 2:1 opioid to 
naloxone, for oral administration. 

Methylnaltrexone has been approved by the 
Scottish Medicines Consortium for restricted use 
by palliative care specialists "when response to 
usual laxative therapy has not been sufficient". 
It will not be reviewed by Nice as its impact on 
population health and NHS budgets does not 
warrant the resources required to conduct this 
type of appraisal. 

Breakthrough cancer pain (BCP) has been defined 
as "a transient exacerbation of pain that occurs 
either spontaneously or in relation to a specific 
predictable or unpredictable trigger despite 
relatively stable and adequately controlled 
background pain". The typical episode reaches 
peak intensity within three minutes and is of short 
duration (median 30 minutes). 

Assessment is important to allow identification 
of any underlying cause and re-assessment of the 
treatment of background pain. For many years, 
the only pharmacological treatment option for 
BCP or incident pain (eg caused by a procedure or 
movement) was immediate release morphine or 
oxycodone equivalent to about a sixth of the daily 
dose of oral opioid. 

Oral transmucosal fentanyl is now marketed 
specifically for the management of breakthrough 
pain. Three products are licensed: Actiq lozenges 
(lollipop), Abstral sublingual tablets and Effentora 

Table 1 . Equivalent potencies of oral opioids to oral morphine 

Oral drug 

Duration of action (hours) 
(standard release preparations) 

Potency equivalence to 
morphine (oral to oral) 



80 (sublingual) 






















Equivalent potencies are only approximate and can be unpredictable. When converting from one 
opioid to another, it is often appropriate to use a lower dose than the suggested equivalence above. 
Close monitoring for side effects and efficacy is mandatory, especially at higher doses. A fuller version 
of this table, including drug notes, is available at 

Source: National Electronic Library for Medicines (www nelm 

buccal tablets. They have a faster onset of action 
than immediate-release oral formulations of 
morphine or oxycodone (10-15 minutes compared 
with 20-30 minutes) and a shorter duration of 
action (one hour compared with four to six hours). 
The transmucosal formulations are licensed for use 
in patients taking at least 60mg of oral morphine 
per day, or an equivalent dose of another opioid 
(eg 25 microgram transdermal fentanyl per hour, 
30mg oral oxycodone daily), for at least a week. 
With all these products the rescue dose cannot be 
predicted from the background opioid dose, so 
titration is necessary. 

Intranasal fentanyl (Instanyl) has recently been 
introduced for the management of breakthrough 
pain in adults who are already receiving opioid 
therapy for background pain. The initial dose is 50 
microgram (one spray) repeated after 10 minutes 
if necessary. Another intranasal formulation 
(Nasalfent) may soon be marketed. 

Immediate-release fentanyl products are useful 
for relieving BCP for patients who experience 
sedation or other side effects after other 
immediate-release opioids 

Around 65 per cent of people on a care register 
dying at home or in a care home receive 
anticipatory prescribing. The Just in Case Box 
is dispensed for use in the treatment of an 
individual patient and is held in the patient's 
room. It is stocked with medicines that may be 
used when the healthcare team agrees the patient 
is in the dying phase. Examples of good practice in 
the supply, storage and safe use of these 
medicines are available at the Cold Standards 
Framework website. 

Future developments 

The Good Practice Guide in the Management of 
Controlled Drugs, updated in 2009, provides 
recommendations on the safe possession, storage, 
supply, and administration of controlled drugs. At 
present nurse and independent pharmacist 
prescribers may not prescribe, possess, supply, 
offer to supply, administer and give directions to 
administer controlled drugs specified in schedules 
2 to 5 of the Misuse of Drugs Regulations 2001. 
The regulations may be amended to allow this to 
happen in the future. 

Every year about half a million people die in 
England. The number of deaths is set to rise due to 
an ageing population and greater prevalence of 
long-term conditions. Community pharmacists 
actively contribute to multi-professional teams 
involved in palliative and end of life care for 
patients through dispensing for patients receiving 
care in the community, care homes, hospices and 
from out-of-hours services. 

By completing training programmes relevant to 
local and national services, members of the 
pharmacy team can ensure appropriate access of 
medicines, contribute to symptom management 
and allow patients to feel supported in their 
preferred place of care. 

Further reading is available in the full version online 

Doreen Cochrane MRPharmS is an 
independent pharmacist and trainer 

successfully complete the 5 Mir 
this Update article online (p18). 

ite s est for 


The management of problems 
such as constipation, nausea and 
agitation in end of life care 

17.07.10 17 






4 15 Travel health ▼ 18 Epilepsy meds ► 19 Incontinence ► 22 Coalition plans ► 25 First impressions 

End of life care: part 1 

How does renal impairment affect morphine dosing? 
How much more potent than morphine is oxycodone? 
Which opioid analgesic is most effective for 
breakthrough cancer pain? 

This article discusses end of life care, focusing on pain 
management. It includes information about morphine, 
diamorphine, oxycodone and fentanyl. It also discusses 
breakthrough cancer pain and future developments. 

Read more about pain control in terminal care on 
the Patient UK website at 
painrelieflO. A diagram of the WHO analgesics ladder 
can be found on the Pain Talk website at 

Revise your knowledge of the doses and formulations 
of the opioid analgesics available by reading section 4.7.2 
of the BNF. 

Find out more about breakthrough pain by reading the 
information for professionals from breakthroughcancer at and about 
Just in Case boxes from the Gold Standards Framework 

Consider the aspects of pain management in the end 
of life care of patients you have known. How could you 
improve your services? 

Are you now confident in your knowledge of pain 
management in end of life care? Could you give advice 
about this to a patient or carer? 

C minute test 

m0 What have you learned? 

Test yourself in three easy steps: 

Step 1 

Register for Update 2010 and receive a unique PIN number 

Step 2 

Access the 5 Minute Test questions on the C+D website at 

Step 3 

Use your PIN to complete the assessment online. Your test score will be 
recorded. If you successfully complete the 5 Minute Test online, you will 
be able to download a CPD log sheet that helps you complete your CPD 

Registering for Update 2010 costs £37.60 (inc VAT) and can be done easily 
at or by calling 0207 921 8425. 

Signing up also ensures that C+D's weekly Update article is delivered 
directly to your inbox free every week with C+D's email newsletter. 

Get a CPD log sheet for your portfolio when you successfully complete 
the 5 Minute Test online. 

Practical Approach 

Antibiotic prescribing in epilepsy 

John Rose, a regular patient at the 
Update Pharmacy, has just handed 
in a prescription for ciprofloxacin 
250mg tablets, one bd for five days. 
In the dispensary pharmacist David 
Spencer reviews it and remembers 
that John has epilepsy. 

He recalls that a couple of days 
earlier John had come in asking for 
advice about lower urinary tract 
symptoms that he was suffering. 
David suspected that it might be a 
UTI and referred him to his GP. 

David brings up John's PMR on the 
computer, which shows that he is 36 
years old and has a long history of 

epilepsy that has been successfully 
controlled for several years with 
carbamazepine 600mg bd, and that 
he takes no other prescribed 
medication. David goes out to speak 
to John. 

"Hi," he says, "I see that Dr Berkoff 
has prescribed you some antibiotics." 

"Yes. She thought your suspicion 
that I had a water infection was right, 
took a urine sample to send away to 
confirm it and prescribed these 

"I don't suppose she told you why 
exactly she prescribed these?" 

"She did actually. She said it 
wasn't the antibiotic that she would 
usually give for a water infection, but 
that those might react badly with my 
epilepsy tablets. And she said 
something about them 'upsetting my 
folate', but I don't know what that 
means. She's also sending me to the 
hospital for a blood test, and said I 
needed to have one regularly." 

"How are you getting on with the 
carbamazepine?" David asks. 

"Fine. I haven't had a seizure in 
years," John replies. 

"Alright," David says, "I think I'll 
just have a word with Dr Berkoff 
before I dispense your prescription." 

1. What is the problem that David 
has identified in relation to the 

2. What other drugs might cause 
the same problem? 

3 What did Dr Berkoff 's remark 
about folate mean and was it 

4. How often should John have a 
blood test? 

1. Ciprofloxacin is an inappropriate 
choice of antibiotic as quinolones are 
known to trigger seizures or lower 
seizure threshold in patients prone 
to them. Trimethoprim is a suitable 
choice (see 3, below). 

2. Analgesics: NSAIDs, opioids; 
antibacterials: cephalosporins, 
penicillins; antidepressants: most 
classes and particularly tricyclics; 
anti-emetics: metoclopramide, 
prochlorperazine, cyclizine; 
antipsychotics, especially 
chlorpromazine, clozapine; 
cholinesterase inhibitors: donezepil, 
galantamine, rivastigmine. 

3. Trimethoprim increases the 
plasma concentration of phenytoin 
and also has an increased antifolate 

effect, but there is no such interaction I 
with carbamazepine. In any case, the I 
risk of folate deficiency even with I 
phenytoin is unlikely with a short 
course of trimethoprim for a UTI. 
4. Carbamazepine can cause 
transient leucopenia and the 
incidence is high (10-20 per cent); a 
full blood count should be 
undertaken every three to six 
months during the first year of 
therapy. Carbamazepine is an enzyme [H 
inducing drug and a full blood count 
plus liver enzymes test should be 
undertaken every two to five years 

Based on case study 1, C+D Skills for 
the Future: MURs in Practice. 
Programme 2, no. 12. March 2006 

To get Practical Approach emailed 
to you every week, sign up to C+D's 
free CPD bulletin at www.chemist 

For more Practical Approach 
scenarios, go to www.chemist 

18 Chemist Druggist 17.07.10 



15 Travel health j 16 End of life: pt 1 19 Incontinence 22 Coalition plans f 25 First impressions 



Help customers to overcome the embarrasment of bladder weakness and you 
could see your share of this growing market soar, finds Emma Wilkinson 

ncontinence may be an embarrassing 
problem, but it is also a very common one. 
Prevalence very much depends on who you 
ask and how you define the condition, but in its 
2006 guidance Nice estimated that more than a 
third of women suffer urinary incontinence from 
time to time. 

Around 4 to 7 per cent of women under 65 and 
4 to 17 per cent of those over 65 suffer from the 
problem on a daily basis. And it is not just a 
female problem - it is thought that one in 13 of 
the entire adult population buys incontinence 
products. Yet according to the Bladder and Bowel 
Foundation, many people do not seek help or, 
when they do, receive substandard care 

From the pharmacist's point of view, demand 
for incontinence products is on the rise, with the 
bladder weakness market seeing double digit 
ear-on-year growth in sales of pads, liners and 

r pants. Tena dominates the market, perhaps 
unsurprisingly given the extent of its marketing 
campaigns, but own label products are starting to 
come into their own. 

The big question is how pharmacists can best 
support customers who feel nervous about 
shopping for and asking questions about products 
for bladder weakness. : 

Five tips for boosting 
incontinence product sales 

1. Invest in staff training to help both 
pharmacy assistants and customers feel 
more comfortable talking about 

2. House your incontinence section within 
the feminine hygiene category. 

3. Take time to assess possible causes of 
bladder weakness with patients, such as 
medication side effects. 

4. Offer dietary and lifestyle advice to help 
customers cope with bladder weakness. 

5. Ensure customers know that their 
concerns can be discussed professionally 
and discreetly, such as in a private 
consultation room. 


Total value of incontinence market 


Growth of incontinence market 2009-10 


Pharmacy share of incontinence market 

Source: Kantar Worldpanel, 52 weeks to May 16, 2010 

17.07.10 19 






14 Travel health ! 16 End of life: pt 1 20 Incontinence ; 22 Coalition plans 25 First impressions 

The incontinence market is purchased by 7.5 
per cent of the adult population, and shows 
strong growth year on year. 

Own label products are becoming more 
prominent as the market matures, and are 
growing faster than brands. However, Tena 
remains in number one position, with a strong 
presence across all sub-categories. 

As well as having the most expensive 
products, bladder weakness pants are the 
fastest growing area in value terms. 

Due to the nature of the market, over-45s 
account for approximately 90 per cent of sales, 
but as awareness of the condition increases 
there is opportunity to attract younger buyers. 

The pharmacy sector has seen strong value 
growth faster than the total market this year, 
especially within the pants sub-category. 

Boots is particularly dominant, accounting 
for a large percentage of sales, but as the 
incontinence market becomes less specialist, 
Tesco, Asda and Sainsbury's are increasing 
share year on year. 

Grocers in general are more prominent this 
year, with shoppers now purchasing in Tesco, 
Sainsbury's and Morrisons more frequently 
than in pharmacies. 

The pharmacy sector is especially strong in 
the pants sub-category, which is considered 
more specialist. 

Market changes 2009-10 
Incontinence products 

Total market value 




3:::\p,:i8d v own label 



Total market 


Own label 



Own label 



Source: Kantar World pan el, 52 weeks to May 16, 2010 

Data and analysis provided for C+D by Kantar Worldpanel (strategic 

insight director, Tim Nancholas) 


Karl Baggott, category manager at 
Lloydspharmacy, believes that one key element is 
making sure customers are buying the most 
appropriate product for their needs so they will be 
satisfied and return to the store. He adds: "We 
know that some people may feel embarrassed 
when buying incontinence products but pharmacy 
can offer a discreet environment, which helps to 
take away the embarrassment factor, enabling 
customers to ask questions about products and 
pharmacists to advise customers on products that 
are best suited to their needs." 

To ensure the pharmacy team is able to offer 
appropriate, helpful advice it may be worth 
investing in some training. 

In the spring of this year, Numark ran training 
workshops aimed at pharmacy support staff in 
conjunction with SCA Hygiene Products, which 
manufactures Tena. Those taking part were 
advised not only on technical knowledge 
regarding different types of bladder weakness and 
pros and cons of different types of incontinence 
products, but also tips on how to encourage 
customers to talk with minimum embarrassment. 

The training led to a 100 per cent boost in sales 
of Tena products in the stores taking part. 

Yvonne Tuckley, training manager at Numark, 
says it is vital to involve counter assistants in 
being able to advise on incontinence. "Customers 
are likely to feel awkward and embarrassed, which 
may deter them from seeking advice," she says, 
"and without proper training pharmacy staff may 
feel reticent to discuss the subject, too." 

Once staff are comfortable talking about and 
advising on bladder weakness, it is also vital that 
nervous customers are easily and quickly able to 
find what they are looking for. Emma 
Charlesworth, retail excellence manager at 
Numark, says: "The customer needs to feel at ease 
in terms of making a purchasing decision. Even 
though recent development in the category has 
meant that incontinence is no longer stigmatised 
there still exists some embarrassment around the 
issue, therefore helping your customers to avoid 
any embarrassing conversations will ultimately 
lead to increased sales." 

She recommends using recognisable brands to 
direct customers to the section, which is best 
housed within the feminine hygiene category 
"Having a poorly merchandised female health 
section will ultimately drive customers away from 
the category and because this category is 'needs' 
rather than 'wants' focused, an illogically 
merchandised section will drive them out of the 
store," Ms Charlesworth explains. 

The pharmacist also needs to take the time to 
properly assess why a patient is suffering from 
incontinence and if there are any simple steps that 
can be taken to alleviate the problem. For 
example, says Wendy Lee, pharmacist at The Co- 
operative Pharmacy, it could be a side effect of a 
medication the patient is taking. 

"Sometimes patients take diuretics too late in 
the day and they end up needing to go to the 
toilet at night time but they may not be able to 
get there quick enough," Ms Lee says. "The 
pharmacist can also establish whether patients 
are drinking lots of caffeinated drinks as these 
have a diuretic effect. 

"Drinks containing barley or dandelion in 
addition to tea, coffee and cola may also have a 
diuretic effect." 

She adds that dietary and lifestyle advice can 
sometimes make a big impact on patients' quality 
of life. Simply advising patients to avoid drinks 
that have a diuretic effect and not to drink too 
much just before they go to bed may make all 
the difference. 

And explaining that there is a range of 
medication and incontinence products on the 
market to help to solve or alleviate these 
problems can really put a patient at ease. 
"Reassure them that their requests can be dealt 
with professionally and discreetly," Ms Lee adds. 

"Sometimes customers don't want to come in 
personally to discuss this matter in the pharmacy 
so we can encourage them to ring in and discuss 
this with the pharmacist in confidence. Always 
offer the customer the option of a private 

How the sub-categories compare 
Total market Pharmacy 



+ 58.9% 



+ 15.4% 











+ 56.2% 

Source: Kantar Worldpanel, 
52 weeks to May 16, 2010 


20 Chemist Druggist 17.07.10 

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Deirdre Whyatt, from Natural Health Pharmacy 
in Norwich, took four of her staff along to an 
incontinence training session organised by 
Numark and SCA Hygiene Products, which 
manufactures Tena. 

They were taken through the range of products 
offered by Tena and given an explanation about 
which product to use in what circumstances and 
how best to arrange those products on the stock 
floor to enable the customer to quickly and easily 
find what they are looking for. 

Retail supervisor Ann Smith says: "We have 
put into practice the training given, the shelves 
have been arranged according to the trainer, the 
boxes are in order and the customer can see her 
way clearly." 

She adds: "The display is private but prominent, 
the customer is happy to ask for advice and we are 
nore confident to give the advice - personally I 
nave not lost a sale since that evening and Tena is 
Dne of our biggest sellers in this area." 
She says people are often embarrassed about 

Since the Tena/Numark incontinence training seesion, staff from Norwich's Natural Health Pharmacy have 
been more confident in assisting customers who may be embarrassed about asking for advice 

discussing incontinence, but since the training 
staff have been able to spend more productive 
time with customers, who come back time and 
again for more help. 

"We are also often asked for products 
for gentlemen and are happy to discuss this 
with our customers, who appreciate a matter 
of fact understanding of their problem," Ms 
Smith says. 

"I would recommend this sort of training to 
all who work in this business as customers are 
happy and relieved to be helped to spend their 
money on the right product instead of trying 
lots of different ones first." 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on incontinence 



Do I offer customers with 
incontinence a good service? 

Consider how I could better serve 
customers with this condition. 


Organise training for myself and 
staff and/or remerchandise my 
incontinence products section. 

EVALUATE Are customers with incontinence 
better served in my pharmacy? 

Brand Watch: Tena 

Tena, a range of more than 70 
incontinence products, 
undoubtedly dominates the 
bladder weakness market - a 
category showing strong year-on- 
year growth. 

Tena brand marketing manager 
Emma Lazenby says there are 
approximately six million women 
and three million men in the UK 
who experience bladder weakness. 

Through mainstream advertising 
aimed at both men and women, 
the Tena name is certainly one that 
resonates with consumers. 

And although incontinence 
products are available through 
many retailers, the pharmacy is 
able to provide an extra level of service, she says. 

"Tena Men has proved very successful in pharmacy. We offer both level 
one and level two product in pharmacy, whereas in most other retailers 
we only offer level two. 

"This provides a point of differentiation for pharmacies and allows 
pharmacists to be able to talk about the full range of products directly 
with the consumer." 

In addition, she says, pharmacists are able to advise based on the 
patient's needs, and in some cases offer private consultation rooms. 

"Tena offers a training course for pharmacists and counter staff to help 
them feel more comfortable in approaching consumers who are reluctant 
to discuss their situation," Ms Lazenby adds. 

Pharmacist Support 

working for pharmacists & their families 


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A confidential service providing financial 
assistance in times of need. Just one of a range 
of services provided by Pharmacist Support - the 
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17.07.10 hem ist Druppist 21 






15 Travel health < 16 End of life: pt 1 19 Incontinence 22 Coalition plans \/ 25 First impressions 

The coalition script 

While this week's health reforms dominate the news agenda, the coalition government's 
policies on tax, employment law and consumer rights will also affect pharmacies. 
Chris West and Adam Bernstein explain what the changes mean to you 

And so it came to pass. After much 
pre-election angst, warning how 
destructive a hung parliament would 
be, the public declined to give any party the 
majority required to form a government. In the 
extraordinary days that followed a coalition 
government emerged, pledging an era of new 
kind of politics. 

From day one, the talk was predictably all 
about the deficit and the need to tighten public 
spending. While health spending will be protected, 
the government is still committed to finding the 
£15 to £20 billion of savings identified by NHS 
chief executive David Nicholson - "more for less" 
is the mantra. 

On health policy, there have been few surprises. 
The Queen's Speech set out the government's 
legislative programme, including a health bill 
making provision for CP commissioning, an 
independent NHS Board and huge cuts within the 
Department of Health and NHS management, 
with strategic health authorities and primary care 
trusts bearing the brunt. 

The revised operating framework, issued a 
month after the election, was Andrew Lansley's 
first opportunity to begin unpicking the parts of 
the NHS that don't fit his future plans. 'Process 
targets' were in the firing line, as he issued a range 
of new tests that reconfigured services would 
have to pass. 

New services must have support from 
commissioning CPs, be evidence-based, and 
strengthen patient engagement and choice. These 
must be front of mind for any new service being 
proposed within the NHS. 

For pharmacy, it is clear that there is a valued 
role to play in providing quality patient services in 
the community. As ever with a change of 
government, there remain questions on the crucial 
detail of policy. How will commissioning groups 
work in practice, and how can pharmacy best 
partner with these new bodies? What will the new 
health bill mean for the pharmaceutical needs 
assessment and quality accounts, both of which 
would have major impacts on the sector? 

The health white paper published this week (see 
p4-5 and p12 for details), and public health white 
paper due in the autumn, will both provide 
opportunities for pharmacy to demonstrate how 
it can continue to play a central role in the NHS. 

Aside from this, of course, is the issue of 
how long the coalition lasts. Leading figures from 

22 Chemist+Druggist 17.07.10 

The coalition's policies on tax and business will affect phamacy as much as their health reforms 

both governing parties are unsurprisingly talking a 
good game about the partnership lasting the full 
five years. But behind the scenes, backbenchers 
arriving on the government benches have 
been looking quizzically at each other - socially 
liberal Lib Dems and traditional right wing 
Conservatives wondering how it is they came to 
be sitting side by side. 

Already there have been small signs of 
rebellion. Lib Dem MPs openly discussed voting 
against the emergency budget in protest over the 
VAT increase, while Conservative backbenchers 
last week tabled a string of presentation bills 
proposing right wing policy shifts on Europe 
and crime. 

The first weeks of this government have given 
us a steer of what to expect, but a number of 
questions remain. 

The health white paper will begin to provide 
some of those answers, but for the NHS - and 

those involved in and alongside it - a long 
summer of briefing, positioning and reconfiguring | 
lies ahead. 

Chris West is an associate director of political p 
consultancy Insight Public Affairs 

CPD Reflect • Plan • Act • Evaluate 


Tips for your CPD entry on government policy 

REFLECT How could new government 
policies affect my pharmacy? 

PLAN Read the coalition's programme 
for government and its health 
white paper 

ACT Identify policy changes that will 

affect my pharmacy and service 
development opportunities 

EVALUATE Am I prepared for policy changes? 

Get the latest news on the health white paper 

More coalition policies 
affecting pharmacies: 

1 . Consumer rights 

Consumer rights are given a small leg up in a short section of the coalition's 
"programme for government". Of the nine elements detailed, the ones 
that might cause comment from businesses concern new powers to define 
and ban excessive interest rates on credit and store cards; a seven-day 
cooling off period for store cards; a move to force credit card companies to 
provide information in a standard electronic format so customers can see if 
they are getting a good deal; and stronger consumer protections and - 
interestingly - measures to enhance customer service in both the private 
and public sectors. 

2. Business 

From enterprise policies, which are high on the agenda, business should 
expect to benefit from the original tib Dem policy of 'one in, one out' rule for 
law and regulations, where burdens are reduced or kept level, and the 
introduction of 'sunset' clauses where laws and regulations die after a given 
period of time. At the same time, inspections from the authorities will 
become targeted based on risk. British business will be pleased to know that 
the coalition is going to work towards making small business rate relief 
automatic while also lowering the corporation tax rate by simplifying reliefs 
and allowances. 

3. Employment law 

Not unsurprisingly, employers face serious employee management burdens. 
The coalition promises to review employment legislation so that regulation 
overall remains fair while giving all flexibility. The national minimum wage 
(NMW) is supported by the coalition, so employers can expect labour costs 
to rise over time as the NMW rises with each new Low Pay Commission 
annual report. The coalition is proposing that people stay in work longer; 
taking changing demographics, and the state of the economy into account, 
it's an unfortunate necessity. To do this it plans to remove the default 
retirement age, set the earliest a person can receive a state pension at age 
66, and remove the compulsory annuitisation of a pension at age 75. It also 
plans to change the rules surrounding occupational pensions to make them 
more attractive. 

Despite the recent passing by the last government of the Equalities Act, 
the coalition will make extensions to the rules on equality at work including: 
new rules promoting equal pay; the right for all employees to request 
flexible working; and new measures to end discrimination at work. 

Those who have been unemployed, and who wish to start up their own 
business, will be able to seek help from a new programme called Work for 
Yourself. The programme would offer access to mentors and start-up 
finance. New proposals will make the receipt of benefits - unemployment or 
ncapacity - conditional on a willingness to work. At the same time, the 
benefit system will be altered to incentivise people to work. 

A. Tax 

Unfortunately, rises in taxation are a key part of deficit reduction. However, 
it's not all bad news. The coalition proposes to increase the income tax 
personal allowance, eventually, up to £10,000 per annum, the goal being to 
help lower and middle-income earners. This will, though, be funded by an 
ncrease in the national insurance thresholds and an increase in capital gains 
tax (CCT) rates for non-business assets by making the CGT rate close to, or 
the same as, the individual's normal rate of personal taxation. The coalition 
also wants to remove the 50p tax rate as soon as possible, which could be 

ooner rather than later if that rate doesn't bring in much revenue. Sadly, 
For those about to inherit a pile, the inheritance tax threshold is not going to 
De raised. Those who travel by air will see travel taxed by the plane rather 
"han by the person. A greater proportion of taxation is to be raised by 

nvironmental taxes and, as with the previous Labour government, further 

fforts to deal with tax avoidance will be made. 


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4 15 Travel health 


16 End of life: pt 1 

19 Incontinence % 22 Coalition plans 25 First impressions 


steps to making 
a good impression 

Whether talking to your boss or your customers, theatre expert Ron 
Aldridge tells Hannah Flynn how to make that first impression count 

Make a good first 

People are making conscious and 
jnconscious decisions on all the 
nformation they are taking in," says 
:heatre director Ron Aldridge, "from 
/our breathing and your face to your 
overall body language. This is 
because humans are expert at 

eading each other." 

First impressions are crucial to 
pharmacists, he says, as your 
:ustomers will be deciding whether 
or not they want to come back - 
and people make up their minds 
within the first 45 seconds of 

2. Improve your 

'You can't say, 'I have presence and 
:harisma'; those are not god-given 
'ifts," Mr Aldridge says. "They are 
;kills other people say you have and 
:an be worked on and improved." 

Mr Aldridge explains that the 
/vay you feel and the way your 
:ustomer feels are crucial to bear 
n mind when trying to improve 
ihe way you present yourself. 

Firstly, you must be aware that 
the way you are feeling will come 
across in the way you are speaking, 
ie says. 

Secondly, people don't remember 
what you say for long, but they do 
'emember the way they felt when 
/ou spoke to them 

3. Breathe properly 

Most people do not breathe 
oroperly, says Mr Aldridge, but 
they can learn how. He suggests a 
quick exercise that can develop 
Deople's breathing and takes only 
one minute a day. 

He explains: "Breathe in, and if 
your chest comes up you are doing it 
wrong. So, sit down and breathe in 
and feel your stomach move out. 
ifou can do this in front of the TV, in 
a meeting or in the car. 

'Then you need to count from 
one, as far as you can on one breath 

Most people can get to 20 or 30 
at first. 

"If you try counting on one breath 
every day you should eventually be 
able to count to 60. Once you can 
do this, you are breathing properly," 
he says. 

A. Deal with tension - 

"The first thing people do when they 
are feeling tense is clench their 
shoulders," says Mr Aldridge, "but 
that is very noticeable. I suggest 
people clench their buttocks and 
thighs - this is known as the singer's 

Mr Aldridge adds that people 
are often unsure of what to do with 
their hands when they are speaking 
to someone. 

He asks: "When was the last time 
you got up in the morning and said 
to yourself, 'What shall I do with my 
hands today?' " 

If this bothers you, he suggests 
placing your hands on top of each 
other and bring them to your chest 
as this makes you appear more open 
to being approached. 

5. Explain yourself 

Mr Aldridge says: "Professional 
actors practice until they can't get it 
wrong, and pharmacists know their 
subject well, so you can't get an 
explanation wrong. Pharmacists 
should work on that assumption." 

He recommends thinking about 
the clearest way you can explain 
something to a person before saying 

CPD Reflect • Plan • Act • Evaluate 

Tips for your CPD entry on personal presentation 

REFLECT How confident am I about the way I present myself in 
my pharmacy? 

PLAN Consider how better personal presentation could, boost 
customer confidence and loyalty. 

ACT Use the tips in this guide to improve my presentation. 

EVALUATE Am I more confident approaching and talking to customers 
and have their reactions and loyalty improved? 

it. As you speak to more and more 
people, it should get easier. 

6. Learn to speak in 
the major key 

Listen to news readers as they are 
very good at this, advises Mr 
Aldridge. People listen to what they 
have to say as they are speaking 

He says pharmacists must make 
sure they keep channels of 
communication open, and one of the 
best ways to do this is to focus on 
how you finish speaking at the end 
of a line. 

He explains: "Don't lose energy at 
the end of a sentence, go up to keep 
it positive. This will make people feel 
more comfortable as they know 
where they are with you." 

7. Keep an open face 

Finally, Mr Aldridge says, 
pharmacists must ensure they keep 
an open face when they are 
approaching people. 

"An open face means not letting 
your eyebrows fall," he explains. "I 
don't mean walking around with 
your eyebrows raised to the sky, but 
keep a relaxed facial expression. 

"This is used a lot by comedians 
but it can be used in all kinds of 
ways." Using an open face will 
show you are offering help, Mr 
Aldridge says. 

Theatre director Ron Aldridge 
was speaking at the annual 
CAMRx convention in Windsor 
earlier this month. 



(f~ ■/ I have recently qualified as 
\^ a pharmacist. What career 
paths and progressions are open 
to me in community practice and 
how should I go about climbing 
the career ladder? 

Lloydspharmacy HR business 
partner Becky Laycock (pictured) 

A The profession is experiencing 
unprecedented progress and 
development, and the skills of 
pharmacists have never been greater 
in demand. With millions of visits a 
day, pharmacists are at the forefront 
of the public's health and wellbeing 

When you first qualify as a 
pharmacist there's a lot to get used 
to. Whether your role is in 
community or hospital pharmacy, 
you will start to understand the 
elements of your role that most 
appeal to you. The opportunities 
available will largely be dependent 
on the type and size of organisation. 
In general, if your future lies in a 
clinically focused role, there are lots 
of opportunities within organisations 
to work within a support function, as 
a trainer, as a superintendent 
pharmacist, roles that are focused on 
external relationships with business- 
to-business customers and many 
others, utilising your clinical skills 
and professional expertise. Gone are 
the days of a pharmacist hidden 
behind the counter counting tablets. 

If you want to progress to a senior 
or general management role, you 
can work your way up the ladder in a 
larger organisation. 

For either route you should speak 
to your line manager and/or your 
HR department about opportunities 
that are available and what skills and 
experience are required to fulfil your 
preferred career path. Create a plan 
that sets out how you intend to 
develop this experience and skills, 
which should include the roles you 
could move to in order to gain the 
appropriate skills and experience. 

17.07.10 Chemist* Druggist 25 



ACT REQUIRED for our brand new 
modern Pharmacy. 

Established Independent Pharmacy 
for many years. 

Please contact SV!r. D Rajani 07786 691810 or 



Applicant must be motivated, enthusiastic, 
customer friendly and hard working. 

• Minimum NVQ2/NVQ3 

• Experience Essential 

• Good Communication Skills 

Please call: Sue on 07867 523235 or emai! your CV to 

acy Technicians 

Want a new challenge? We are expanding our Care 
Home Pharmacy operations in London & Glasgow 

Coatbridge, ACT. Up to £25,000 pa, 

NVQ3: Up to £16,575 pa, NVQ2: Up to £12,675 pa. 

MDS experience favourable but not essential. Full Training provided 

London NE, NVQ2: Up to £14,000 pa 

Driving Licence Essential 

37.5 hours per week, 4 weeks annual leave + Bank Holidays 
Please contact Nisha Patel on • 
020 8527 1071 

or email ^> 


Dedicated to your 





Full Time 

1. Based in Northampton. 

2. Minimum NVQ 2 Qualification. 

3. Minimum 2-3 years hospital or community experience working in a busy 

4. Experience of working with a range of PMR and labeling systems. 

5. Demonstrated commitment to ongoing career development. 

6. Excellent salary/benefits package (dependent on experience) 

If you wish to apply for the above vacancy, please send your CV to: 
Closing date for applications: 23rd July 2010 however Medco Health Solutions 
reserve the right to close early on successful applicant appointment. 

Brigg, North Lincolnshire 

Riverside Pharmacy is a surgery-based 
pharmacy in the market town of Brigg. 
It is part of a group of 3 Numark branded 
pharmacies in Brigg, Broughton and 

You will work alongside the 
Superintendent Pharmacist and receive 
excellent training in all aspects of 
pharmacy using the Numark Programme 
to prepare you for the changing, extended 
role of the future pharmacist with the 
opportunity to work with other healthcare 

To apply, please send your application 
and CV to: 

Medipharmacy Group 

placement available from 
Aug 2010 in London, 
West Ealing. 

Email CV to 

Employers, have you received your free listing? 

Call 0207 921 8123 

Buttercups Training 

Accredited courses for pharmacy 
support staff: 

• Medicine Counter Assistant course 

• Level 2 for Dispensing Assistants 

• NVQ3 in Pharmacy Services 

• Checking Courses 

• Pre-registration Pharmacist Programme 

• CPD Academy for all support staff 

• Funded Advanced Apprenticeship 
programmes (age restrictions apply) 

New for 2010: 

• Team leading 

• IT 

Enrol any time and experience our supportive learner 
journey with 24/7 helpline and access to learner 
management system. 

For more details see our website or telephone 
01 15 9374936. 

One of our friendly team is always 
available for advice. 

0115 937 4936 



School of 

in partnership with 



Springboard: sign up now 
for the 2010-1 1 pre-reg 
training programme 

Springboard is a pre-registration programme offered by 
Medway School of Pharmacy in partnership with C + D. 
Springboard equips pre-registration students with the skills 
and confidence to ensure a smooth transition from pharmacy 
graduate to practicing pharmacist. 

The Springboard pre-registration training programme consists 
of eight study days facilitated and delivered by staff from C + D 
and Medway School of Pharmacy covering a wide variety of 
topics, enabling students to meet the appropriate competencies 
in the RPSGB's student handbook. 

Springboard is unique in that by the end of the course the 
students will have also completed an accredited medicines 
use review training programme, the C+D Counterpart 
pharmacy assistant course, the Practice Certificate in Pharmacy 
Management course, as well as receiving a subscription to an 
online practice exam question website. 

Springboard also includes a training day for the 
pre-registration tutor. 

The cost of Springboard is from £1,200 (+ VAT) per student. 

For more information phone 0207 921 8413 
or email 

26 Chemist Druggist 17.07.10 

Advertise your product to community pharmacy every Saturday 
Call 0207 921 8123 

Marie Stopes International are experts in sexual 
and reproductive healthcare and work closely with 
the NHS to provide local services. 

If you would like leaflets about unplanned pregnancy, 
abortion, chlamydia, vasectomy or female sterilisation 
call us for a free sexual health pack. 

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Pharmacy Development Group 

Gain the benefit of share of profits without 
having to invest your own money in a 
share purchase scheme 


Trading group terms aggregated discount up to 
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Find new ways to influence your profit 

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Full support on Pharmacy New Contract allowing 
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Call Freephone 0800 526074 & ask for Customer Services 
quoting reference No. CDJULY 
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HANDBOOK 2009/ 1 

Your pocket guide to Locum Pharmacy Practice 




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I l 

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Cost effective specialist legal advice 
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We can assist with buying, selling, merging 
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Hilary D'Cruz or Jas Singh 
01543 466 660 


Chemist+ Druggist remains the clear leader 

in influencing stock decisions* 
*Linda Jones Associates Industry Survey 2009 

1 7.07.10 Chemist Druggis; 27 


Looking to buy or sell a pharmacy? Advertise here 

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LEASE TO BE AGREED, PRICE £275,000 phis s.a.v. 

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If you are planning to sell your pharmacy 
you should be preparing for it now. 
Call us today for a no obligation confidential discussion: 
We can provide:- 

An up to date appraisal of the market 

A free valuation of your pharmacy 

R7f A comprehensive list of information and 

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01494 722224 

"We are the only NPA 
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Free, no obligation valuation service 
f Nationwide database of registered buyers 
Established network of contacts within 
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Professional guidance and management of 
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Discounted, fixed rates on legal fees through 
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Tel 01829 238 197 email us at 
or visit our website at 

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We have over 900 people on our register, from all over 
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Call 07767 611774 or email: 
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28 Chemist : Druggist 17.07.10 

Advertise your service to community pharmacy every Saturday 
Call 0207 921 8123 



As the leading tax consultants to retail pharmacists we 
have clients throughout the UK. 

We know many pharmacists are happy with their accountants 
but are not getting proactive tax advice. 

We have the answer. You don't need to change accountants 
- we can work alongside them solving your tax problems 
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Phone Anne Hutchings on: 01494 722 224 

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modiplus provides the following 
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17.07.10 Chemist Druggie 29 

m Got a story for Postscript? 

Pharmacists and GPs: pen pals? 

A few weeks back, C+D asked you to pen your responses to infamous GP columnist Dr Tony 
Copperfield, who had a few choice words to say about pharmacists. The responses were 
excellent. If fact, some were so good, we thought we'd share them... 

Dr Copperfield's original letter to C+D 

Despite what my book [Sick Notes] 
says, I quite like pharmacists. Partly 
because we're all supposed to be 
part of one big primary care 
family, running hand in hand in 
soft focus through fields of corn 
in a concerted effort to save our 
patients from viral-, pollen- or 
emotional-induced sniffles. 
But also because you do very 
occasionally bale me out 
('Dr Copperfield, can I just 
check you really did want 
to prescribe some 
potentially bone- 
capsules for this child's 
conjunctivitis? Or would you rather 
I dispense the ointment?') And you do it 

Readers respond 

Dear Dr Copperfield 

I'd love to get past my identity crisis of selling 
vases with silk flowers and photo frames. I'd love 
to concentrate on developing and providing 
professional services that are recognised and 
appreciated by our fellow healthcare colleagues. 
I'd love to be able to fully devote my time to 
ensuring I don't miss the need to 'bale out' one of 
my prescribers. 

However, the problem is that unlike our 
medical colleagues 1) we can't force people to 
take up our services by withholding treatment 
until they attend; Z) we can't demand funding to 
provide these services or threaten to withdraw 
them; 3) we don't have the luxury of having a 'list' 
of patients who come exclusively to us for whom 
we get income if they turn up or not; and 4) the 
government and their elected bodies tell us they 
want us to develop these roles but won't pay us. 
Instead they allow manufacturers to restrict 
supply of medicines through selected wholesalers 
who then impose a discount on us that is less than 
the amount the government claws back. And they 

without laughing at me. 

You know there's a but 
0"*' coming, though. And it's 

this. But I do wonder 
^ whether you've ever 
, resolved that tension 
between being a health 
professional and being a 
shopkeeper. Because while 
your shelves are filled with 
vitamins, tonics and herbal 
rubbish, I find it hard to take 
seriously all the good work you 
do. It's as though you're doing a 
customer's cardiovascular risk 
prediction on the one hand and, on 
the other, telling him his fortune. Get 
over your identity crisis and I'll view 
you in a much more sympathetic light. 
Though I'll have far less to write about. 

"Stop your hypocrisy, 
Dr C, and I'll give you 
back some of the 
respect I used to have 
for GPs" 



reduce our opportunity to benefit from being a 
good 'businessman' by reducing purchase profit. 

So, instead of criticising us for trying to make a 
better living for ourselves in any way that can't be 
taken away/reduced by the powers that be, 
support us with these bodies Allow us to take 
over some of the mundane roles that your skills 
don't need to be used for, allowing you to focus on 
the patients who really need you. And in doing so, 
support us in that we need to be adequately 
reimbursed for us to develop professional services 
that you guys will recognise as such and value. 

Perhaps then we can run through our field of 
corn, if not hand-in-hand at least side by side. And 
just ask us for some stories about our customers 
wanting to order their 'ferocious sulphate' tablets 
and we'll give you plenty to write about! 
Careth Rowe, Nantymoel Pharmacy, Bridgend 

Gareth wins a copy of Dr Copperfield's latest 
book, Sick Notes. 

Dear Dr Copperfield 

Are you a not-for-profit salaried GP? Or are you, 
like me, owner of a business that has the NHS as a 

Stop your hypocrisy, Dr C, and I'll give you back 
some of the respect I used to have for GPs. 

PS The latest news from the dispensing doctors 
in their posh health centre near me is that they 
have appointed a 'business development manager'. 
Will Dr C's practice be doing the same soon? 
Peter Hopley, Brewery Lane Pharmacy, 
Newcastle upon Tyne 

just a message to Dr Copperfield 

The doctor should be thankful his book is not 
handwritten, since pharmacists would be the only 
people who would be able to read it! 
Shelley Chapman, Co-operative Pharmacy, 

To the purely altruistic Dr Copperfield 

Yes, you are right. In the past there may have well 
been some conflict between our professional role 
and the need to make money. Now, of course, 
that we have the respect of colleagues and are 
paid sensible rates for the services that we 
perform, we can make a reasonable living and 
provide them in a professional manner working in 
collaboration with other health professionals. Oh, 
and if I hadn't had to make an appointment to get 
you to alter these prescriptions... 

Dr Copperfield merely shrugs and writes 
"delusional" on the sick note he has in front of 
him. The meeting is over. 
Martin Fisher, Freefield Pharmacy, Lerwick 

Would you like to see a regular 
column by Dr Copperfield? 

Vote at 

30 Chemist Druggist 17.07.10 

Where is the pharmacy 
industry going? 

Tricky question. Simple answer, 

Just about anyone who is anyone in the 
pharmacy business is gathering at The 
Pharmacy Show this October. There will be 
more than 220 leading suppliers (the 
most ever), over 50 world class conference 
speakers, senior executives, leading 
regulators, top policy-makers, all the major 
associations and most importantly of all 
your industry peers, people just like you . . . 
thousands of frontline pharmacists, 

Supported by Education Partners CPD Recording partner Training Partner Media Partners 

is ^ © E23 ®= S >rsl 4 aZ Medi0 CD 

pharmacy executives, owners and support 
staff. There's plenty to talk (and learn) about. 
Whether it's the new frontline healthcare 
responsibilities facing community 
pharmacies, strategies and tactics for 
trading through challenging times or the 
need to source profitable new retailing 
ideas, you can get it all at the UK's largest 
source of world-class, live CPD education 
and the biggest sourcing event for 
medicines, equipment, technology, retail 
and services. And, remarkably, it's all FREE. 

Go to 

for the full programme and to get your free 
delegate pass. Or call 01926 485151 

Pharmacy Show 

10th-llth October 2010 / The NEC Birmingham 

Pictured L to R: Bernard Mweseka, Pharmacy Manager, 
Day Lewis; Dvyesh Patel, Pharmacy Technician, 
MED-Chem Pharmacy; James Davies, Academic 
Pharmacist, London School of Pharmacy; Mike Ritson, 
Superintendent, ABC Drugstores, Richard Harnld, Retail 
Sales Manager, Lloydspharmacy, Raj Bali, Pharmacist, 
Lloydspharmacy, All Gul Ozbek, Owner-Superintendent, 
MED-Chem Pharmacy 

New licensed liquid Simvastatin. 
A heartfelt solution for patients who can't 

swallow tablets. 


New licensed liquid Simvastatin is effective and easy to take. Many statin 
patients fail to take their medication regularly, 1 making an effective 
treatment, ineffective. 2 

One common problem is difficulty with swallowing, 1 so Rosemont have 
launched the only licensed liquid Simvastatin as an easy to swallow 
alternative. Pleasant tasting and in a choice of 
strengths it is a welcome solution for patients 
who are unable to swallow tablets. 

Abbreviated Prescribing Information. SIMVASTATIN 20mg/5ml and 
40mg/5ml Oral Suspension. Consult Summary of Product 
Characteristics before prescribing. Presentation: White to off-white 
oral suspensions. Therapeutic Indications: Hypercholesterolemia: - 
Treatment of primary hypercholeslerolaemia or mixed dyslipidaemia, as an 
adjunct to diet, when 1 response to diet and other non-pharmacological 
treatments is inadequate, Treatment of homozygous familial 
hypercholesterolaemia as an adjunct to diet and other lipid-lowering treatments 
or if such treatments are not appropriate. Cardiovascular prevention:- 
Reduction of cardiovascular mortality and morbidity in patients with manifest 
atherosclerotic' cardiovascular disease or diabetes mellitus, with either normal 
or increased cholesterol levels, as an adjunct to correction of other risk factors 
and other cardioprotective therapy. Posology and Method of 
Administration: Adults: The dosage range is 5 - 80mg/day depending on 
condition given orally as a single dose in the evening. Adjustments of dosage, 

■ If required, should be made at intervals of not less than 4 weeks, to a maximum 

■ of 80mg/day given as a single dgse in the evening. The 80mg dose is only 
recommended in patients with' severe hypercholesterolaemia and high risk for 
rarrjovascularxbmplications. No modification of dosage should be necessary 
in patients iwiln moderate renal insufficiency. In patients with severe renal 
insufficiency, dosages above 10mg/day should be carefully considered. 
Children: 00-17; years of age, boys Tanner Stage II and above and girls who 
are at least one year post-menarche) with heterozygous familial 
hypercholesterolaemia^ starting dose is 10mg once a day in the evening; The 
recommended dosing; range. is 10-40 mg/day. Adjustments should be made' 
at intervals of 4 weeks or more,- The experience of simvastatin in pre-pubertal 

ren is limited. Elderly: Nd dosage adjustment is necessary. Contra- 
indications: Hypersensitivity to' simvastatin or to any of the excipients. Active 
ent elevations of serum transaminases, 
nt administration of potent CYP3A4. 

inhibitors. Precautions: Myopathy/Rhabdomyolysis. Hepatic effects; 
persistent increases (to > 3 x ULN) in serum transaminases have occurred in 
a tew adult patients who received simvastatin. When simvastatin was 
interrupted or discontinued in these patients, the transaminase levels usually fell 
slowly to pre-treatment levels. The product should be used with caution in 
patients who consume substantial quantities of alcohol. Interstitial lung disease; 
exceptional cases of interstitial lung disease have been reported with some 
statins, especially with long term therapy. Excipient Warnings; 
parahydroxybenzoates which may cause allergic reactions, Interactions: The 
risk of myopathy, including rhabdomyolysis, is increased during concomitant 
administration with fibrates. There is a pharmacokinetic interaction with 
gemfibrozil resulting in increased simvastatin plasma levels. Rare cases of 
myopathy/rhabdomyolysis have been associated with simvastatin co- 
administered with lipid-modifying doses (>1g/day) of niacin. Drug interaction's 
associated with increased risk of myopathy/rhabdomyolysis; Potent CYP3A4 
inhibitors - Contraindicated with simvastatin. Gemfibrozil - Avoid but if 
necessary, do not exceed 1 0mg simvastatin daily. Ciclosporin, danazol, other 
fibrates (except fenofibrate) - Do not exceed 10mg simvastatin daily, 
Amiodarone, verapamil - Do not exceed 20mg simvastatin daily. Diltiazem - Do 
not exceed 40mg simvastatin daily. Fusidic acid - Patients should be closely 
monitored. Grapefruit juice - Avoid grapefruit juice when taking simvastatin, 
Effects of other medicinal products on simvastatin. Combination with 
itraconazole, ketoconazole, HIV protease inhibitors, erythromycin, 
clarithromycin telithromycin and nefazodone, is contraindicated. Ciclosporin - 
the dose of simvastatin should not exceed 1 0mg daily. Very rare cases of 
elevated INR have been reported, Pregnancy and Lactation: Simvastatin 
Oral Suspension' is contraindicated during pregnancy. It is not known whether 
simvastatin or its metabolites are excreted in human milk. Women taking 
Simvastatin Oral Suspension should not breast-feed their infants. Effects on 
Ability to Drive and Use Machines: Simvastatin Oral Suspension has no 

or negligible influence on the ability to drive and use machines. Undesirable 
Effects: Investigations: Rare: increases in serum transaminases, elevated 
alkaline phosphatase; increase in serum CK levels. Blood and lymphatic system 
disorders; Rare: anaemia, Nervous system disorders: Rare: headache, 
paresthesia, dizziness, peripheral neuropathy. Very rare: memory impairment. 
Gastrointestinal disorders: Rare: constipation, abdominal pain, flatulence, 
dyspepsia, diarrhoea, nausea, vomiting, pancreatitis. Skin and subcutaneous 
tissue disorders: Rare: rash, pruritus, alopecia. Musculoskeletal, connective 
tissue and bone disorders: Rare: myopathy, rhabdomyolysis, myalgia, muscle 
cramps. General disorders and administration site conditions: Rare: asthenia. 
Hepato-biliary disorders: Rare: hepatitis/jaundice. Very rare: hepatic failure. 
Psychiatric disorders: Very rare: insomnia. Overdose: There is no specific 
treatment in the event of overdose. Shelf Life and Storage: 12 months 
unopened, 1 month opened. Do not store above 25°C. Legal Category: 
POM. Pack Size and NHS Price: 20mg/5ml, 1 50ml - £99.50 40mg/5ml, 
150ml - £152.00. Marketing Authorisation Holder: Rosemont 
Pharmaceuticals Ltd, Rosemont House, Yorkdale Industrial Park, Braithwaite 
Street, Leeds, LS11 9XE, UK.Marketing Authorisation Number: 
20mg/5ml PL 00427/0146, 40mg/5ml PL 00427/0147, Date of. 
Preparation: May 2010. 

References: 1 , Benner JS, Glynn RJ, Mogun H. Long-term persistence in use 
of statin therapy in elderly patients. JAMA 2002; 288: 455-61 . 2. Crouch M. 
Am Fam Physician 2001 ; 63: 309-20, 323-4. 


The source of liquid solutions. 


Rosemont Pharmaceuticals Ltd. Rosemo'nt House, Yorkdalejlndustrial Park, Braithwaiie Street, Leeds LSI I ?XE T +44 (0) ( I 3-244 1 400 F +44 (0) I I 3 245 3567 
E Sales/Customer Sc'yUe: T +44 (0) I I 3/244 1999 F +44 (0) I 13 246 0738 W 

Mcif-n iboi adv< rs event reporting can !><• found .it Adverse events should also be reported to Rosemont Pharmaceuticals Ltd on 01 13 24 4 14 00.